Brief Cognitive-Behavioral Therapy to Mitigate Subacute Suicidal Ideation Among Youth

Abstract

There is a critical need to develop brief, scalable interventions for youth that can facilitate accessible, cost-efficient, and least-restrictive support, while addressing key drivers of suicidal ideation (SI). We present an overview of a novel cognitive-behavioral therapy module which targets perceived burdensomeness toward others (PB), an established driver of SI. Empirical work indicates that PB precipitates SI and is modifiable in youth. Hence, the primary aims of the module are to decrease levels of PB and downstream SI in youth who present with subacute suicidal ideation (i.e., SI not requiring intensive, restrictive services). The four sections of the Give to Others (GO) module include (1) rapport-building and an introduction to the cognitive triangle, (2) identification of burden-related thoughts and cognitive restructuring strategies, (3) a social contribution (or “give to others”) activity for teens, and (4) a parent message activity related to youth social contribution. This paper provides guidance to clinicians treating youth with subacute SI for whom there are limited brief evidence-based manualized protocols. The acceptability and feasibility of the module in the management of subacute SI is promising, with additional outcome data collected in an ongoing randomized controlled trial.

Suicidal ideation (SI) is increasingly prevalent and impairing in youth, with 30% of female and 14.3% of male high school students reporting seriously considering attempting suicide (Gaylor et al., 2023). SI can precipitate costly, restrictive, and intensive services (e.g., inpatient hospitalization, emergency department visits) or law enforcement contact (e.g., initiated by school personnel). Distal and potentially proximal drivers of youth suicidal ideation include suicide-related cognitions (e.g., hopelessness, low belongingness; Wolfe et al., 2019; Swee et al., 2020), interpersonal stressors and conflict (Buitron et al., 2016), emotion dysregulation (Hatkevich, Penner, & Sharp, 2019), and psychiatric disorders (Gould et al., 1998). In this paper, we focus on a specific interpersonally oriented cognition, perceived burdensomeness (PB), which involves the belief that one is a liability or drain on others’ resources. PB is a theory-driven and evidence-based driver of SI. Meta-analyses indicate a strong correlation between PB and SI (Ma et al., 2016; Chu et al., 2017) and studies have indicated that PB is a risk factor of SI in youth specifically (Buitron et al., 2016; Buitron, Hill, et al., 2020; Buitron, Vaclavik, et al., 2020; Hill et al., 2018; Hunt et al., 2020). There is an underdeveloped evidence-base for interventions that can mitigate drivers of SI, including a lack of preventive and brief interventions that could target PB among youth experiencing subacute SI (i.e., SI not requiring intensive, restrictive services). Such interventions would pave the way toward facilitating least-restrictive, cost-efficient, and accessible support for youth.

Established evidence-based treatments for youth suicidality, such as Dialectical Behavior Therapy for Adolescents (DBT-A), Cognitive Behavior Therapy for Suicide Prevention (CBT-SP), Interpersonal Psychotherapy for Depressed Adolescents (IPT), and Attachment-Based Family Therapy (ABFT), have demonstrated efficacy in reducing suicidal ideation and related symptoms (e.g., DBT-A: Mehlum et al., 2014; CBT-SP: Stanley et al., 2009; IPT: Tang et al., 2009; ABFT: Diamond et al., 2010). However, these approaches are typically multicomponent, multi-session protocols (often 12–24 weeks) that address broad domains including emotion regulation, interpersonal skills, family dynamics, and relapse prevention. These protocols are important in the context of higher clinical acuity and the presence of clinical and family resources that allow for lengthy treatment. In contrast, there remains a need for a brief clinician-friendly tool or intervention that can be flexibly implemented within or in tandem with standard outpatient care to target PB in youth with subacute SI.

This paper presents a novel treatment module that has the potential to reduce subacute SI in youth, with promising initial tests of acceptability, feasibility, and efficacy. Specifically, the Give to Others (GO) module is designed to target PB in youth by shaping positive beliefs about social contribution (and corresponding self-efficacy) and facilitating prosocial, helping behavior that is incompatible with burden-related cognitions. Spanning two clinical trials, the module has been administered to a total of 47 clinic-referred youth (i.e., referred to outpatient mental health services) to date in South Florida. The first pilot clinical trial used an interrupted time series design to test the module among 18 youths (mean age = 14.22, 83.3% female) who were referred to outpatient mental health services for internalizing symptoms and reported elevated levels of burdensomeness. This first trial indicated that the GO module could statistically significantly reduce levels of PB in clinic-referred youth receiving standard cognitive-behavioral therapy over 12 sessions (Buitron et al., 2022). Further, families in this trial consistently reported high acceptability and a large majority of youths (79%) and their parents (83%) independently completed at-home module activities (Buitron et al., 2022). An additional mechanistic randomized controlled clinical trial is currently being conducted to build on these pilot findings and assess effects on suicide-related outcomes. Twenty-nine youths (mean age = 14.93, 55.2% female) who were clinic-referred, endorsed a suicide risk screen, and reported elevated levels of burdensomeness have received the intervention in this trial. Initial data on feasibility is again promising because a large majority of youth (86%) and parents (79%) independently completed at-home activities related to the module. These findings collectively support feasibility and acceptability with forthcoming outcome data that will inform larger-scale testing, refinement, and adaptations of the GO module.

The GO module in its current iteration can serve as a brief strategy to mitigate burdensomeness, and potentially downstream suicidal ideation, in a way that can be readily understood and used by mental health providers in the community. The theoretical rationale and evidence-informed components of the GO module outlined in this paper can serve as a guide for enhancing cognitive-behavioral therapy (CBT) interventions and as the impetus for further theory-driven intervention development research for suicide prevention in youth.

The Give to Others (GO) Module

Conceptual Model for GO

The interpersonal theory of suicide (ITS) serves as the foundational framework for the GO Module (Joiner, 2005). According to Joiner, the desire for suicide emerges in individuals in part from cognitions of burdensomeness toward others (i.e. the combination of self-directed hatred and a sense of liability in an interpersonal context; Joiner, 2005; Van Orden et al., 2010; Buitron, Hill et al., 2016). The interpersonal theory underscores that burden-related cognitions are often misperceptions not aligned with others’ actual views. Furthermore, clinical and theoretical extensions of the theory posit and demonstrate that perceived social contribution, or the inverse of self-directed liability, is a protective factor in relation to SI (Hill et al., 2024) and a promising target for clinical interventions among at-risk youth aimed at reducing burdensomeness and SI (Hill & Pettit, 2019; Zullo et al., 2020; Buitron et al., 2022). By fostering positive feedback and parental messaging, interventions targeting social contribution are also well-positioned to shape positive self-regard and directly counter self-hatred. Increasing and facilitating opportunities to shape one’s own social contribution and positive self-regard, per theory, is critical to mitigate burdensomeness and downstream SI (Olson et al., 2022), a concept which supports the development of an intervention with strong focus on contribution.

Treatment development studies have applied the ITS to adaptations of traditional CBT strategies (e.g., chain analysis, identification of cognitive distortions, evidence gathering). Protocols include a self-administered CBT intervention delivered in a web-based platform which leveraged cognitive (self-administered evidence gathering) and behavioral strategies (writing a plan to engage in contribution) which found statistically significant reductions in burden-related cognitions and non-significant reductions in suicidal ideation among youth in a non-clinical setting (Hill & Pettit, 2019). Another protocol was examined by Zullo and colleagues (2022) wherein they compared standard intensive outpatient programming with a protocol that included activities designed to increase opportunities for social contribution, receive positive social feedback, and address cognitive distortions about contribution toward others. In the context of this intensive care setting, they found high acceptability and non-significant reductions in burdensomeness and suicidal ideation at discharge. The current iteration of the GO module therefore aligns with these efforts in other settings (e.g., intensive care, self-help) and similarly combines common strategies of CBT with the theoretical and empirical work on the ITS. Further, it tailors these strategies to foster youth social contribution specifically in the context of parent-involved outpatient therapy, and for youth at subacute risk of suicide. Specifically, the module uses CBT strategies involving discussion of the cognitive triangle, chain analysis, identification of cognitive distortions, evidence gathering, generating alternative cognitions, and the planning and practice of prosocial behavior (Buitron et al., 2022).

As discussed above, an ongoing trial of the GO module is evaluating it as a brief standalone intervention and an adjuvant intervention in the context of long-form CBT. Clinicians opting to use the strategies in the GO module may judge which format is most indicated and feasible. The GO module in standalone format may be suitable for subacute cases with prominent burden-related cognitions reported at baseline suicide risk assessment, while embedding the module may be preferable when broader protocols involving additional skills (e.g., emotion regulation) are needed, and when the family’s and setting’s resources allow for longer treatment. In our pilot work so far, 29 youth received the module as a standalone modality (inclusive of suicide risk assessment and management) and 18 embedded within weekly CBT for internalizing problems. The module could also be embedded in non-CBT approaches. For example, the GO module could complement DBT’s interpersonal effectiveness content by specifically assessing and targeting burden-related cognitions and conducting contribution-focused activities, which would not be directly or consistently addressed in standard interpersonal effectiveness discussions about things like general reciprocity and communication. When leveraging the GO activities as part of a clinical toolkit, the GO and Parent Message Activities (discussed below) are essential components, while general CBT primers and timing of intervention may be adapted as appropriate depending on relevance and length and type of intervention.

Brief Overview of GO

The GO Module addresses current empirical and clinical gaps by targeting an established driver of SI, with a streamlined and straightforward manual, and by being highly scalable via high resource efficiency. Further, the GO module is designed to be flexible so it could be administered at any point in an ongoing treatment protocol or as a brief, standalone intervention with standard suicide risk assessment and management. Prior therapy involving cognitive strategies (e.g., identification of cognitive distortions), and out-of-session assignments (e.g., pleasant activity scheduling) could facilitate the module but is not necessary in a brief protocol. To ensure a generalizable approach, the module was developed in both English and Spanish within a multicultural setting. Our pilot work involves many families who are Hispanic, bicultural, bilingual, and/or immigrants. The intervention development was led by an investigator who shares these demographic and sociocultural characteristics and who grew up in the same area, along with a group of clinicians who were, in part, also from similar backgrounds. Activity examples in the manual were systematically co-developed with input from bilingual/bicultural clinicians and families via qualitative work to ensure broad relevance for diverse families. Further, clinicians are encouraged to adapt contribution activities to align with family values and norms to maximize cultural competence and feasibility. Additionally, the module incorporates user-friendly psychoeducational handouts to guide adolescents throughout the session, with the goal of enhancing engagement and understanding of the material.

The GO intervention is designed to involve parents in treatment, so it is not appropriate when the clinician judges that parents may not contribute to the session components in a productive way (e.g., parent is not able to engage actively in teen’s treatment, parent’s own distress interferes with his or her ability to contribute productively in child’s treatment), which can be the clinical scenario particularly in higher acuity situations. While the GO intervention is tailored for adolescence, a high-risk window for the development of suicidal thoughts and behaviors, this developmental stage spans a wide age range and individual age- and developmental-based differences should be considered. The module is designed for youth who are able to identify and reflect upon their thoughts, behaviors, and feelings, and is applicable to most adolescents. However, when working with younger adolescents, clinicians could take on a larger role in facilitating the cognitive aspects of the intervention. The idea of reframing one’s experiences and cognitive self-examination may be new to young teens, so clinicians may choose to spend more time on this section and scaffold young teens’ abilities to identify and change cognitions. Additionally, young teens have different access to resources than older teens. This should be considered when planning at-home behavioral activities and choosing tasks that are realistic and feasible.

Stages of the GO Module

The module involves the application of the cognitive triangle, cognitive restructuring (Taking Another Look), a youth contribution activity (Give to Others [GO] Activity), and an activity in which parents develop a novel approach to communicating with their teens (Parent Message Activity). Table 1 outlines the components included in the core and follow-up sessions and approximate time allocated to each component for a 1-hour core session. Maintaining the theme of flexibility, providers may choose to split the components across multiple sessions, particularly in practice settings with different time configurations, and spend more or less time on a given component depending on how youth engage with the module activities. Suggested session scripts (in bold font below) may also be adapted as needed. Of note, the GO module is designed to be administered only after standard suicide risk assessment and safety planning (Pettit, Buitron, & Green, 2018) have been completed, ensuring integration with standard suicide prevention practice.

Table 1.

Module Components

Core Session	10 minutes: Introduction / Cognitive Triangle 20 minutes: Taking Another Look Activity 15 minutes: Teen GO Activity 15 minutes: Parent Message Activity
Follow-up (after planned GO activity)	5 minutes: Check on GO activity 5 minutes: Check on parent message activity 5 minutes: Wrap-up

Introduction and Cognitive Triangle

The core session begins individually with teens. Clinicians introduce themselves and set the agenda of activities for the rest of the module. Here, clinicians introduce a visual representation of the cognitive triangle, with the idea that there is a feedback loop between emotions, thoughts, and actions, as a conceptual foundation for the cognitive and behavioral tasks that will follow. Teens first apply the triangle concept to a positively valenced situation such as one of their favorite leisure activities, and connect the links in the chain of emotions, thoughts, and actions in these positive situations. Clinicians are encouraged to briefly discuss the interests that teens disclose in this initial exercise, so that this discussion represents a brief primer on CBT concepts and also builds rapport with teens. Thereafter, clinicians facilitate the application of the cognitive triangle concept to a distressing situation as a segue to discussing burden-related situations. Having a self-report assessment of burdensomeness (e.g., Interpersonal Needs Questionnaire) is instrumental in eliciting burden-related thoughts and situations. However, while burden-related cognitions are directly reported by a large majority of teens experiencing suicidal ideation, some teens underreport their suicide-related beliefs during sessions. In this case, clinicians can illustrate the cycle of burden-related thoughts and behavior:

“One example could be a high schooler having trouble with Algebra homework. He knew his dad could help him understand the homework, but he thought his dad was tired of helping him and would get annoyed with him, so he didn’t ask for help. He just struggled with the homework by himself, and then tried to avoid the problem by scrolling on his phone. This made him feel more hopeless.”

Clinicians can then provide guidance as needed to help teens correctly identify the burden-related thought, behavior, and feeling.

“As you can see from this example, thinking that we make others’ lives worse or that others would be better off without us makes us do things that make us feel worse over time. Because teens are trying to figure out their family and social life, it can be really hurtful to experience these thoughts and it can get us stuck in negative feelings.”

Taking Another Look Activity

Once clinicians facilitate teens’ understanding of the link between burden-related thoughts, help-seeking or social avoidance behavior, and difficult emotions (and suicidal ideation for some teens), then cognitive errors are explored while building the rationale for the GO Activity. In this section, cognitive restructuring begins.

“Just like thinking that you make things worse for others can make you feel bad, finding out how much you give or can give to other people and make their lives better can make you feel good. Remember, the way you think and the things you do are connected to how you feel. Let’s take a closer look at your thoughts. Then after we do that, we will focus on the things that you can do to make someone’s day better.”

Following this, clinicians begin to explore examples of cognitive errors with teens to help them identify which are most descriptive of their burden-related thoughts. An abbreviated list of cognitive errors, or “thinking traps”, are displayed in the handout. These include four specific traps that are relevant in our experience: mind reading, negative filter, overgeneralization, and perfectionism. It might be necessary for clinicians to provide suggestions of how teens’ reported burden-related thoughts could fit specific thinking traps. The point of this section is to help teens understand how their thoughts of being a burden can arise from common cognitive errors and how quick identification of these errors can prompt further self-examination. Clinicians can then use a compact, heuristic cognitive approach via the “Go-to Questions.” That is, a small set of queries that teens can use in self-questioning after recognizing they are in a thinking trap or having persistent negative thoughts. For this, clinicians provide teens with a handout that contains the following questions that tap into evidence gathering, alternative thought generation, and perspective taking:

• What is another way to look at this situation?

• What would you tell a friend in this situation?

• How many times has this situation happened in the past?

• What would be a more helpful thought in this situation?

Selecting one or more questions and working through them allows teens to push back on their burden-related thoughts. The provider must offer scaffolding and assistance as needed to help teens respond to these questions, recognizing that certain questions may be more effective for specific difficult situations and that this self-questioning approach takes practice. Table 2 illustrates this process of brief cognitive restructuring using the abbreviated list of thinking traps and Go-to Questions. As is often the case, these examples show how PB may manifest as a focus on the negative effect of one’s difficulties on others’ distress and wellbeing.

Table 2.

Examples of brief cognitive restructuring.

Difficult Situation	Burden-related Thought	Thinking Trap(s)	Go-To Question
Arguing with parents about recent decline in school grades.	“I feel like I make their lives worse because I keep messing things up for them, and now they’re frustrated all the time.”	Overgeneralization: Thinking that something bad that happened will happen all the time or drawing broad conclusions from it.	What would you tell a friend in this situation? E.g. “They really care about you doing well in school and things will go back to normal when they see you trying to make things right.”
Having difficulty asking mom for help at night when having suicidal thoughts.	“I feel like my mom is tired of dealing with all of my problems and trying to make me feel better. If I wake her up, she will be even more tired for work.”	Mind Reading: Thinking that we know exactly what others think and feel. Negative Filter: Often focusing only on the negative parts of a situation.	What would be a more helpful thought in this situation? E.g. “My mom would feel better if she knows I go to her for help. She would want to know how I’m doing and help me stay safe, even if she lost a bit of sleep.”

Once teens demonstrate an understanding of the utility of self-questioning amid persistent negative thoughts, clinicians can allude back to the cognitive triangle, shifting the focus from “thoughts” to “actions.” Before proceeding to the action-oriented content, clinicians can collaboratively explore how teens can make others’ lives better. Some teens recognize that they explicitly contribute to others’ lives already, while others would, at a minimum, practice listing prosocial actions as a primer to the GO activity. As clinicians transition into the GO activity, they ensure teens understand burden-related emotions, thoughts, and actions, as well as applicable cognitive errors and a heuristic approach to cognitive restructuring.

GO Activity

For the GO activity, clinicians reinforce the idea of social contribution and prosocial actions as an opposing force or a way to push back on burden-related thoughts and distressing feelings. That is, GO targets reductions in burden-related beliefs via fostering actual contribution experiences that support a positive feedback loop with subjective beliefs.

“We talked a lot about how we think, which is one point on the triangle. It can also be helpful to focus on another point in the triangle, our actions or the things we do. In this case, we can plan to do something that is the opposite of the negative thought of making things worse for others. Even if you think you make things worse for someone, you have the power to do the opposite by doing something to make things better for them. Let’s think of a plan to do that.”

For the GO activity, clinicians will work with teens on developing an activity of their choice consistent with social contribution, essentially prosocial behavior framed to be impactful for others. The key to this approach is fostering self-efficacy toward social contribution (e.g., “you have the power to make things better for others”) and engaging in planning that creates more opportunities for social contribution, as opposed to proposing a rigid and transactional view of giving. This is critical as some teens (a minority of them in our experience) will have difficulty completing their selected GO activity at their first attempt.

Teens are provided a handout featuring a variety of activities centered on giving to others to facilitate their selection of an activity. The activities can include:

• Write a note of encouragement to another teen receiving therapy.

• Help with a household chore that you do not usually do.

• Help prepare a meal for a parent or friend.

• Write a thank you note for a parent or friend.

• Make someone’s day on social media.

• Do the favorite activity of someone you’re close to.

• Do an artistic activity with/for a caregiver or friend that they enjoy.

• Help a family member or friend with their social media (e.g., taking pictures, thinking of post ideas).

• Take your parent or friend out for a treat (if you have a job).

• Make (or buy) a thoughtful gift for your parent or friend.

Clinicians gather specifics about when, where, and how teens will complete the activity. After establishing these details, potential obstacles should be addressed to ensure that teens are able to complete it and then plan accordingly. To assist teens, clinicians can encourage setting up a phone reminder during the session for when they will work on the activity. It is also important to inquire whether the teens are aware of their parents’ availability (if applicable); if the teens are uncertain, the provider can address this when the parents arrive at the session for the following section of the module. If possible, clinicians can provide teens with the option to complete a contribution activity during the session, like the activity of writing an anonymous note of encouragement for other teens receiving therapy in the clinic.

Parent Message Activity

For the final stage of the session, parents are invited to join. Clinicians discuss the potential benefits of parent involvement and obtain teen assent before inviting parents, while noting scenarios where individual administration may be preferred. Further, it is explained to teens that this activity will aim to give their parents the opportunity to communicate with them in a new way. Clinicians then explain to parents that this brief treatment is about building their teen’s sense of contribution toward other people as it is important for their self-esteem, wellbeing, and relationships with others. Parents are prompted to develop a message dedicated to their teens that serves as a reminder of the ways their teens make people’s lives better. Emphasis is made on attempting to communicate in a novel way with teens.

“Sometimes life gets in the way of communicating sincerely about this topic, or maybe you already have regular communication. Regardless, we would like to create the chance to make it happen and really try to go farther than you normally would in your day-to-day lives in telling your teen how they make others’ lives better.”

Parents are informed that the message can be in the form of a letter, a long text message, a voice message, a video, etc., where they can include relevant stories and memories. Clinicians also state that they will not be coaching or pushing parents to make this message a certain way and that this message activity is meant to be between parents and their teens. Setting a target date for when this activity must be completed and presented to the teen is ideal. Similarly to the GO teen activity, clinicians can explore potential barriers that may prevent parents from completing their letter activity and encourage them to set a reminder (e.g., a phone notification) during the session.

For parents who are the recipient of the GO teen activity, this part of the session also presents an opportunity for discussion about the nature of the activity and confirmation of parent availability. Clinicians, when appropriate, can help teens and parents agree on a mutually feasible schedule for completing their respective activities. At the end of the session, clinicians will wrap up the module by thanking them for engaging in this topic, and for being open about negative thoughts and trying new things. We encourage clinicians to provide teens and their parents reminders of their respective activities during the week that follows.

Follow-up Session

Clinicians conduct a follow-up call or session after the core GO session has taken place. The nature of this clinical encounter will depend on whether the module was administered in brief, standalone format or whether it is embedded in a longer form of psychosocial therapy. The primary objective of the follow-up is to reinforce key cognitive takeaways from the module, emphasizing the role that teens play in contributing to the wellbeing of their loved ones.

Review of the GO Activity

The follow-up begins with an evaluation of the adolescent’s experience with the GO activity. For some teens, the activity may yield a positive outcome, reinforcing a constructive interpretation of their actions. When this occurs, it is beneficial to acknowledge teens’ efforts and to highlight this as evidence of their ability to positively influence others through thoughtful planning and intentional actions. In cases where teens perceive the activity negatively, brief cognitive restructuring techniques can be utilized to reframe their interpretation. This may involve prompting teens to reconsider their perspective by referring to questions from the “Taking Another Look” section, and/or consider other ways of contributing and potentially other people in their lives to whom they could contribute. For teens who did not complete the activity, it is important to identify and address the primary obstacles that hindered completion. If the task was perceived as too difficult, strategies should be explored to modify the activity, making it more manageable. Encouragement should be provided to support additional attempts.

Review of the Parent Message Activity

The Parent Message Activity is then reviewed with teens, making a note of the contrast between the positive content of the message and teen’s burden-related thoughts. If appropriate, teens are encouraged to retain the message, either by saving a digital copy or keeping a handwritten letter, or other object (e.g., a parent completed a personalized photo album for their teen in our work) in an accessible location for posterity. In instances where parents did not complete the activity, teens are provided with brief adaptive framing:

“I’m sorry this opportunity didn’t work out. I hope your parent will consider trying something like this in the future. Our session gave them a good reminder of how meaningful these sorts of messages can be. People have a hard time planning things and getting them done for many different reasons.”

To conclude the follow-up, the central themes of the module are reinforced. The teens’ concerns about negatively impacting others or feeling as though they are a burden are briefly revisited in light of the cognitive and behavioral strategies completed. Teens are encouraged to recognize their capacity to positively influence those around them, with numerous opportunities to make things better for others in future interactions including new people with whom they might connect. If applicable, at the end of the follow-up, the importance of preserving the parent message is highlighted (if successfully completed by parent), particularly as a resource during challenging moments. Teens can be reminded that the parent’s efforts were made with intentionality and thoughtfulness, reflecting true sentiments rather than transient feelings made in moments of stress or distraction.

Navigating Potential Challenges

One challenge in administering the GO Module can arise when teens underreport or no longer report PB. That is, teens may report burden-related thoughts in the context of a risk assessment or in another treatment session, but when asked to recall and examine these thoughts, they might avoid disclosure (e.g., to avoid further suicide risk assessment) or have difficulty applying the concepts in the GO Module to their own thoughts and feelings. In this case, it can be helpful for clinicians to elicit burden-related thoughts with direct reference to prior self-report (e.g., referencing specific items previously endorsed on the Interpersonal Needs Questionnaire), and leverage hypothetical examples of teens experiencing burden-related thoughts including the ones listed above. In the context of using hypothetical examples, clinicians can encourage teens to engage in perspective taking and explore how they may feel in these scenarios. Additionally, clinicians can look to draw connections between what teens report and burden-related thoughts in order to gradually approach the subject.

Another potential challenge is difficulty completing out-of-session activities, both from teens and their parents. Depending on the context of whether the GO Module is implemented as a standalone intervention or embedded into longer-form treatment, approaches to address this challenge may differ. For example, in a single-session intervention, a follow-up call should be used to explore why teens were unable to complete the activity, revisit some of the rationale behind the activity, and encourage additional attempts. In the case that a parent fails to complete their portion of the module, clinicians can similarly problem-solve and encourage additional attempts, including in vivo activities during subsequent sessions in the context of long-form treatment. Despite the strong emphasis on a positive message related to teens’ contributions, some parents may have difficulty developing a message that maintains focus on this topic and a positive valence. Clinicians might need to reframe the parent message in a follow-up discussion with teens, for instance, by drawing attention to the message’s positive and novel themes.

Summary and Future Directions

The GO Module, a brief cognitive-behavioral intervention designed to reduce PB and, in turn, SI in youth, has demonstrated promising preliminary effects when embedded within standard outpatient treatment (Buitron et al., 2022). Its potential extends beyond its initial implementation, offering opportunities for broader application and adaptation across various settings and populations. Efforts toward application and adaptation should also be mindful of limitations of the current work, including constraints related to the pilot sample which may not generalize to populations in other regions or from different sociocultural backgrounds. Testing has occurred exclusively in outpatient settings, by design, so generalizability to other clinical contexts (e.g., intensive care) is limited. That is, the GO module is specifically intended to mitigate subacute suicidality, rather than functioning as a primary intervention for acute risk. Further, despite promising data from pilot work, additional research is needed to examine the long-term effects of the GO module.

One promising avenue for implementation is flexibly embedding the GO Module within larger outpatient treatment protocols. The pilot and ongoing work with the module involves administering it either midway through a CBT protocol or as a standalone intervention after suicide risk assessment and safety planning. Future avenues for clinical care should explore whether embedding the module at different points within treatment—such as earlier in a protocol or as a booster session following standard CBT—could be applicable to certain subgroups of youth. In middle and high school settings, there is an opportunity to provide brief interventions to teens who experience subacute suicidal ideation. The GO Module could also be adapted into a curriculum-based workshop or administered by school providers and psychologists including in group settings where contribution can be facilitated within the social milieu. Future evaluations of these clinical scenarios should examine how modifications, such as adjusting to a group modality or school setting, could enhance engagement and effectiveness of the module.

By expanding its implementation across outpatient care and other settings, the GO module has the potential to serve as a scalable, cost-effective intervention that addresses a driver of youth SI. A current federally funded randomized controlled trial (NCT06586645) will inform the refinement of the module toward future adaptations that balance maintaining the module’s theory-driven principles with necessary modifications to optimize its applicability and impact across different clinical situations.

Highlights:

Novel CBT module targets perceived burdensomeness in youth with suicidal ideation

Give to Others (GO) module promotes social contribution to reduce suicidal thoughts

Flexible, scalable intervention for clinicians treating subacute suicidal ideation

Pilot trial shows acceptability; ongoing RCT evaluates efficacy in outpatient care