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. Author manuscript; available in PMC: 2022 May 1.
Published in final edited form as: Behav Ther. 2020 Jul 22;52(3):552–563. doi: 10.1016/j.beth.2020.07.005

Social Problem-solving and Suicidal Ideation among Homeless Youth Receiving A Cognitive Therapy Intervention: A Moderated Mediation Analysis

Jing Zhang 1, Qiong Wu 2, Natasha Slesnick 3
PMCID: PMC8663281  NIHMSID: NIHMS1613927  PMID: 33990233

Abstract

Despite the high prevalence of suicidal ideation and attempts among homeless youth, little research has examined how suicide prevention interventions influence suicide-related risk and protective factors, and ultimately produce positive outcome in suicidality in this population. Drawing on the Diathesis-Stress Model and the Interpersonal Theory of Suicide, the current study examined whether participation in Cognitive Therapy for Suicide Prevention (CTSP) moderated the mediation link between social problem-solving, perceived burdensomeness and thwarted belongingness, and suicidal ideation among a sample of homeless youth experiencing suicidal ideation. Social problem-solving refers to a set of cognitive, emotional, and behavioral coping responses in the face of stressful situations, and it is identified as a potent protective factor in alleviating perceived burdensomeness and thwarted belongingness, and reducing suicidal ideation. Participants included 150 homeless youth (M age = 20.99, range = 18–24; 41% female) who were randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Treatment as Usual (TAU) (n = 75) or Treatment as Usual alone (n = 75). Participants were assessed at baseline, 3, 6, and 9 months post-baseline. Findings showed that perceived burdensomeness mediated the association of social problem-solving with suicidal ideation only among youth participating in the CTSP condition. These findings provide evidence to support the promising effects of CTSP in enhancing the protective effects of social problem-solving on suicidal ideation through the mediating effects of perceived burdensomeness. Findings also have implications for improving intervention effectiveness with a community-based population at high risk of suicide.

Keywords: suicidal ideation, homeless youth, cognitive therapy, social problem-solving, perceived burdensomeness

Suicide is the third leading cause of death among youth and emerging adults aged 10 to 24 years (Miller, Esposito-Smythers, & Leichtweis, 2015). Homeless youth have acutely high rates of suicidal ideation and attempts, with national studies indicating that up to 68% of samples of youth report having at least one lifetime suicide attempt (Rotheram-Borus & Milburn, 2004; Yoder, Whitbeck, & Hoyt, 2010). Compared to housed peers, homeless youth experience stressful life situations characterized by violence, abuse, and street victimization (Gaetz, 2004; Hammer, Finkelhor, & Sedlak, 2002; Kidd, 2006), and these factors are associated with elevated suicide risk (Kidd, 2006; Rew, Grady, Whittaker, & Bowman, 2008). In the face of multiple stressors associated with living on the streets, homeless youth show a lack of social skills required for maintaining social support (Falci, Whitbeck, Hoyt, & Rose, 2011), and are likely to engage in maladaptive coping (Moskowitz, Stein, & Lightfoot, 2013), which may give rise to the feelings of hopelessness and helplessness that precipitate suicide risk among this population (Kidd, 2006). Suicidal ideation is one of the most powerful predictors of suicide attempts and completed suicide (Mann, 2002). In order to reduce suicidal ideation among homeless youth, it is critical to identity the associated risk and protective factors, as well as unravel the mechanisms through which intervention efforts induce change in these factors, and subsequently produce positive changes in suicidal ideation. There is growing evidence that cognitive therapy is effective in enhancing social problem-solving, referred to as a set of cognitive, emotional, and behavioral coping responses in the face of stressful situations (D’Zurilla & Nezu, 1982), and that it contributes to decreased suicide risk (Ghahramanlou-Holloway, Bhar, Brown, Olsen, & Beck, 2012; Wenzel, Brown, & Beck, 2009). However, little is known about the underlying mechanisms through which social problem-solving affects suicidal ideation following the cognitive therapy intervention. Drawing on the Interpersonal Theory of Suicide (Joiner, 2005) and the Diathesis-Stress Model (Clum, Patsiokas, & Luscomb, 1979; Schotte & Clum, 1982, 1987), the current study examined perceived burdensomeness and thwarted belongingness as the parallel mediators connecting social problem-solving and suicidal ideation among a sample of homeless youth experiencing suicidal ideation. The moderating effect of Cognitive Therapy for Suicide Prevention (CTSP; Wenzel, Brown, & Beck, 2009) on this proposed mediation mechanism was also examined.

Social Problem-solving and Suicidal Ideation

Social problem-solving is defined as the “complex, cognitive-affective-behavioral process” (p. 156) by which a person attempts to develop relevant ways of coping with stressful situations (D’Zurilla & Nezu, 1990). D’Zurilla and Nezu (D’Zurilla, 1986; D’Zurilla & Nezu, 1982) propose that social problem-solving includes two processes: problem orientation and problem-solving skills. Problem orientation is the motivational process that involves individuals’ awareness and appraisal of the problems, whereas problem-solving refers to individuals’ ability in defining problems, generating and implementing solutions, and evaluation of the effectiveness of solutions. Drawing on the Diathesis-Stress Model of suicide (Clum et al., 1979; Schotte & Clum, 1982, 1987), deficiencies in social problem-solving, represented as a negative problem orientation such as viewing problems as threats and doubting one’s problem solving ability, and difficulties in identifying problems and generating effective solutions, are associated with maladaptive coping in the presence of stressful life events (Ghahramanlou-Holloway et al., 2012). This likely leads to a state of hopelessness, placing individuals at elevated risk of suicidal thoughts and behaviors. Empirical research shows that individuals attempting suicide tend to adopt passive coping strategies, or have difficulty in producing flexible solutions in response to stressful situations (Ghahramanlou-Holloway et al., 2012). In a systematic review of social problem-solving among adolescents with suicidal behaviors, Speckens and Hawton (2005) reported that poor social problem-solving was consistently found among suicide attempters.

Perceived Burdensomeness and Thwarted Belongingness as Mediators

The Interpersonal Theory of Suicide proposes that perceived burdensomeness and thwarted belongingness are two dynamic and malleable cognitive-affective states that precede suicidal ideation (Joiner, 2005; Van Orden et al., 2010). Perceived burdensomeness describes the belief that one’s life burdens family, friends, and/or society, whereas thwarted belongingness describes one’s perception of social isolation from family, friends, or other groups (Joiner et al., 2009). Individuals develop a desire to die when they experience these two states simultaneously (Van Orden et al., 2010). Research has found a positive relationship between perceived burdensomeness and suicide ideation (e.g., Van Orden, Witte, Gordon, Bender, & Joiner, 2008), as well as between thwarted belongingness and suicide ideation (e.g., Van Orden, Witte, James, et al., 2008). An emerging body of research indicates that perceived burdensomeness is a stronger predictor of suicidal ideation compared to thwarted belongingness (Chu et al., 2018; Chu, Buchman-Schmitt, Hom, Stanley, & Joiner, 2016; Chu, Rogers, & Joiner, 2016).

Research examining the direct association of social problem-solving with perceived burdensomeness and thwarted belongingness is limited. Van Orden et al. (2010) proposes that perceived burdensomeness and thwarted belongingness are influenced by interpersonal and intrapersonal relationships. For example, interpersonal conflicts, particularly family conflicts make one feel like a burden to family members. In one of the first studies exploring the association of social problem-solving with perceived burdensomeness and thwarted belongingness and in line with Van Orden et al. (2010), Chu and colleagues (2018) conceptualized interpersonal functioning as the factor that facilitates this association. Chu and colleagues (2018) posited that individuals with good social problem-solving ability would be able to cope with interpersonal challenges and distress and establish positive connections with others. Effective interpersonal functioning and positive connections are likely to make one feel a valued and integral member of society. Effective interpersonal functioning is also likely to increase one’s self-efficacy and alleviate the perceptions of being a burden to others. That is, through facilitating interpersonal functioning, social problem-solving is expected to attenuate perceived burdensomeness and thwarted belongingness.

Further, Chu et al. (2018) proposed that perceived burdensomeness and thwarted belongingness served as potential mediators linking social problem-solving and suicide ideation. Chu et al. (2018) examined this proposition among five samples including undergraduate students, homeless individuals, primary care patients, and military service members, and found that perceived burdensomeness was a more robust predictor of suicidal ideation and future likelihood of suicidal behaviors compared to thwarted belongingness. This prior research mainly focuses on factors that contribute to the explanation of suicidal ideation, whereas research examining how interventions (e.g., CTSP) may potentially influence the prospective mediating association between social problem-solving, perceived burdensomeness and thwarted belongingness, and suicidal ideation is essentially non-existent.

The Moderating Effects of CTSP

Research suggests that the strength of the mediation association between social problem-solving, perceived burdensomeness and thwarted belongingness, and suicidal ideation is not immutable, but rather likely subject to the influence of external factors (e.g., cognitive and psychological states). For instance, a few recent studies examined factors moderating the effects of perceived burdensomeness and thwarted belongingness on suicidal ideation. These factors include positive factors such as optimism (Rasmussen & Wingate, 2011) and mindfulness (Buitron, Hill, & Pettit, 2017) that mitigate the negative effects of perceived burdensomeness and thwarted belongingness on suicidal ideation, as well as risk factors such as perfectionism and discrimination (Wang, Wong, & Fu, 2013) that exacerbate the negative effects of perceived burdensomeness and thwarted belongingness on suicidal ideation. Similarly, Hirsch, Chang and Jeglic (2012) found that loneliness and life stress moderated the link between social problem-solving and suicidal behaviors.

No prior studies have directly examined factors that may moderate the association of social problem-solving with perceived burdensomeness and thwarted belongingness. According to the conceptualization of moderating mechanisms (e.g., Stanton, Luecken, MacKinnon, & Thompson, 2013), common factors associated with both social problem-solving and perceived burdensomeness and thwarted belongingness can potentially moderate the associations between these variables. Given research conceptualizing both poor social problem-solving (Schotte & Clum, 1982) and perceived burdensomeness and thwarted belongingness (Joiner, 2005) as processes that reflect cognitive rigidity, an external factor associated with cognitive processes is likely to moderate the link of social problem-solving with perceived burdensomeness and thwarted belongingness.

Altogether, these empirical studies and theoretical conceptualizations converge to suggest that therapeutic interventions (e.g., cognitive therapy intervention for suicide), that aims to induce protective cognitive and psychological factors, may have the potential to influence the strength of the mediation link between social problem-solving, perceived burdensomeness and thwarted belongingness, and suicidal ideation.

In line with the Diathesis-Stress Model, cognitive therapy views suicidal thoughts and behaviors as maladaptive coping, likely occurring in individuals who are distressed due to an inability to solve problems (Ghahramanlou-Holloway et al., 2012; Wenzel et al., 2009). Cognitive therapy seeks to alleviate suicidal thoughts and behaviors through restructuring the cognition of stressful situations and changing the negative problem orientation, as well as identifying ways that the problem could be resolved (Ghahramanlou-Holloway et al., 2012; Stewart, Quinn, Plever, & Emmerson, 2009). The efficacy of Cognitive Therapy for Suicide Prevention (CTSP; Wenzel, Brown, & Beck, 2009) has been evidenced among both adults (Brown et al., 2005) and adolescents (Stanley et al., 2009). However, little research has tested how CTSP affects the prospective association between social problem-solving, perceived burdensomeness and thwarted belongingness, and suicidal ideation. As such, in the current study, we focused on how protective effects induced by participating in CTSP would enhance the protective effects of social problem-solving on perceived burdensomeness and thwarted belongingness, and ultimately produce positive change in suicidal ideation.

The Present Study

Using data from a longitudinal clinical trial, the present study examined how CTSP influenced the mediational link between social problem-solving, perceived burdensomeness and thwarted belongingness, and suicidal ideation. The primary outcome paper of this clinical trial showed that youth assigned to the CTSP condition exhibited a faster decline in suicidal ideation compared to youth assigned to the treatment as usual (TAU) condition (Slesnick et al., 2020). In addition to testing the effectiveness of interventions, intervention science urges for research efforts uncovering evidence-based explanations for how and why interventions produce changes in targeted outcomes (Kazdin, 2007; Stanton et al., 2013). As a response to this call, the current study sought to contribute to suicide intervention literature by examining the underlying mediating and moderating mechanisms through which CTSP produces positive changes in suicidal ideation. Extending the extant research supporting that perceived burdensomeness and thwarted belongingness serve as the mediators linking social problem-solving and suicidal ideation (Chu et al., 2018), the current study examined how this mediation association may vary as a function of participating in CTSP. Specially, we hypothesized that participation in CTSP would moderate the mediation association between social problem-solving, perceived burdensomeness and thwarted belongingness, and suicidal ideation. We expected a stronger association between social problem-solving, perceived burdensomeness and thwarted belongingness, and suicidal ideation would be detected among youth receiving CTSP compared to those assigned to the TAU condition. Please refer to Figure 2 as the conceptual model.

Figure 2.

Figure 2.

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Results of parameter estimates for the mediation model with the whole sample. Note. Standardized coefficients are shown in the figure. * p < .05, *** p < .001.

Method

Participants

Homeless youth (N = 150) were recruited from the only drop-in center for homeless youth in a large Midwestern city. Youth were engaged in a randomized trial to test the efficacy of CTSP on reducing suicidal thoughts and behaviors, the primary outcome. Youth between the ages of 18 to 24 years were eligible if they were currently homeless, did not require hospitalization, were able to provide informed consent as determined by Structured Clinical Interview for DSM-5 disorders (First, Williams, Karg, & Spitzer, 2015) psychotic screening, and scored above 16 on the Scale for Suicide Ideation-Worst Point (SSI-W; Beck, Brown, Steer, Dahlsgaard, & Grisham, 1999). SSI-W evaluates the intensity of individual’s specific attitudes, behaviors, and plans to complete suicide. Scoring 16 or higher on the SSI-W is associated with a 14 times higher chance to complete suicide (Beck et al., 1999). In the current study, 80% of the youth reported prior suicide attempts. Table 1 presents the demographic information for the current sample.

Table 1.

Demographic Characteristics of the Current Sample

Variables n (%) Mean (S.D.)
Age 20.99 (1.96)
Sex
 Female 61 (40.7%)
 Male 89 (59.3%)
Race/Ethnicity
 American Indian or Alaskan Native 1 (0.7%)
 Asian, Asian-American, or Pacific Islander 1 (0.7%)
 Black or African American 57 (38.0%)
 Hispanic, Other Latin American 2 (1.3%)
 White, not of Hispanic origin 59 (39.3%)
 Other 30 (20.0%)
Highest degree received
 Vocational 4 (2.7%)
 High School Diploma 79 (52.7%)
 GED 13 (8.7%)
 Associate’s Degree 0 (0%)
 Bachelor’s Degree 1 (0.7%)
 Other 6 (4.0%)
 None 47 (31.3%)
Current marital status
 Single, never married 142 (94.7%)
 Legally married 4 (2.7%)
 Divorced 4 (2.7%)
Number of children 0
 0 106 (70.7%)
 1 26 (17.3%)
 2 and more 18 (12.0%)
Has any child ever been taken out of custody?
 Yes 31 (70.5%)
Number of lifetime suicide attempts 6.11 (9.69)
Length of homelessness 126.74 (198.82)
Score on SSI-W 22.91 (4.84)
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Note. SSI-W = Scale for Suicide Ideation-Worst Point. GED = General Education Diploma.

Procedure

Research assistants approached youth at the drop-in center and screened them for interest and eligibility in the study. Interested youth who also reported current suicidal ideation reviewed and signed an informed consent statement. Youth were then administered the SSI-W and the Structured Clinical Interview for DSM-5 Disorders (SCID) (First et al., 2015) section on psychosis to determine formal eligibility. Youth meeting the criteria for participation in the study completed a baseline assessment. Upon completion of the baseline assessment, youth were randomly assigned to either CTSP + TAU (n = 75) or TAU (n = 75). Follow-up assessments were conducted at 3-, 6- and 9-months post-baseline. Research assistants who conducted the assessment were blind to the treatment condition. Figure 1 presents intervention design and flow of participants. All youth, regardless of treatment condition, were tracked for their follow-up interviews. Participants received a $40 Walmart gift card at the completion of each assessment battery. To improve treatment retention, youth were allowed to meet with their therapist without an appointment, and all youth were offered a $5 food gift card for each session attended. All research procedures were approved by the university’s Institutional Review Board.

Figure 1.

Figure 1.

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CONSORT flowchart. CTSP=Cognitive Therapy for Suicide Prevention, TAU =Treatment as Usual.

Intervention Conditions

Treatment as Usual (TAU). TAU included standard suicide prevention practice, consisting of non-directive, client-centered therapy, and was provided at the drop-in center. The drop-in center provides services to meet homeless youths’ basic needs and also links them to community resources as needed. Compared to CTSP, TAU offered at the drop-in center is unsystematic and not manualized.

Cognitive Therapy for Suicide Prevention (CTSP) + TAU. CTSP is based upon the theoretical assumption that people’s cognition, the way by which people think and interpret their life events, determines their emotional and behavioral responses to those events. Therefore, the treatment focuses primarily on maladaptive cognitions associated with suicidal ideation, and targets vulnerability factors such as poor social problem-solving, hopelessness, social isolation, and impaired impulse control. The treatment is designed as a 10-session treatment with weekly or bi-weekly meetings, with the option of nine additional maintenance sessions, provided within the first 6 months post-baseline. The average number of meetings with therapists was 5.01 (SD = 6.08) among participants in the CTSP+TAU condition and 3.32 (SD = 4.65) among participants in the TAU condition.

Therapist training consisted of readings (manual/book: Wenzel et al. 2009) and a three-day onsite training in the intervention, including role play exercises by one of the original developers, Dr. Amy Wenzel. Dr. Wenzel provided ongoing weekly telephone/skype supervision. Therapists were independently licensed master’s level counselors/social workers hired from the drop-in center. All therapy sessions were digitally recorded. The adherence to treatment procedures was evaluated by Dr. Wenzel using the Cognitive Therapy Rating Scale (CTRS; Young & Beck, 1980). The CTRS is an 11-item scale developed to assess therapist competence, rated on a 7-point scale (0 = Poor, 6 = Excellent). The 11 items are summed to yield a CTRS total score, ranging from 0 to 66. Two therapists received CTSP training and weekly supervision with audiotape reviews. The off-site supervisor, Amy Wenzel, rated 53 sessions for therapist “a”, and 36 sessions for therapist “b”. The score for therapist “a” ranged from 20 to 41, with a mean score = 31.17 (SD=5.54) and for therapist “b” ranged from 13 to 42, with a mean score = 32.26 (SD=6.59). Overall, both therapists scored in the satisfactory range.

Measures

Suicidal ideation was assessed by the Scale for Suicide Ideation – Worst (SSI-W; Beck, Brown, & Steer, 1997), a 19-item interviewer-administered rating scale. The scale measures the intensity of individual’s specific attitudes, behaviors, and plans to complete suicide during the time period. Specifically, respondents were asked to recall the approximate date and situations when they were experiencing the most intense desire to complete suicide in the past 90 days. The total score was computed by summing up the individual item scores. The possible range of score is 0 to 38 with a higher score indicating greater suicidal ideation. The SSI-W has demonstrated internal consistency of .88 (Cronbach alpha). The scale also has established validity, showing significant associations with other measures of suicide ideation including the SSI, the suicide item from the Beck Depression Inventory, and the suicide item from the Hamilton Rating Scale for Depression (Beck et al., 1997). In the current study, the reliability of SSI at baseline and 9 months was .69 and .87, respectively.

Social problem-solving was assessed by the Social Problem-solving Inventory (D’Zurilla & Nezu, 1990). The SPSI is a 25-item, multidimensional, self-report measure assessing social problem-solving ability. It includes five subscales: positive problem orientation, negative problem orientation (reversely coded), rational problem-solving, impulsivity/carelessness style (reversely coded), and avoidance style (reversely coded). A total score was generated by summing up the subscales, with a higher score showing better social problem-solving abilities. Internal consistency and test-retest reliability (Cronbach’s α > .90 and r = .91) and concurrent validity with other measures of social problem-solving and depressive symptomatology have been found (Hawkins, Sofronoff, & Sheffield, 2008). In the current study, the reliability of SPSI at baseline and 3 months was .87 and .85, respectively.

Thwarted belongingness and perceived burdensomeness, the two components of suicidal desire as conceptualized by the Interpersonal Theory of Suicide, were measured by the Interpersonal Needs Questionnaire (INQ; Van Orden, Witte, Gordon, et al., 2008). The INQ includes 25 items that are rated on a 7-point Likert scale. The instrument has demonstrated internal consistency with alpha coefficients ranging from .85 to .89 (Van Orden, Witte, Gordon, et al., 2008). The current study utilized the INQ at baseline and the 6-months assessment, with alphas as .82 and .78 at baseline, and .86 and .86 at 6 months, for perceived burdensomeness and thwarted belongingness, respectively.

Covariates included youth’s race (two dummy coded variables, being White vs. non-White, and being other minority races vs. White and non-Black), reported on a demographic questionnaire at the baseline assessment. Youth’s sex was first included in the analysis, but later removed because of a lack of significant correlations with other study variables.

Analytic Plan

The descriptive analysis was conducted with SPSS (version 24; IBM Corp., 2015). A path model was applied to test the multiple-group mediation model with the Mplus software (Muthén & Muthén, 2017). The percentage of missing data ranged from 12.7% to 14.0%. Little’s MCAR test (Little, 1988) indicated that data were missing completely at random, χ2(61) = 51.63, p = .80. As recommended, we used full information maximum likelihood algorithm for missing data estimation (Enders & Bandalos, 2001). Further, we included the root mean square error of approximation (RMSEA), the comparative fit index (CFI), and the Tucker Lewis index (TLI) as the model fit indexes, with a RMSEA of .05 and below and a CFI/TLI of .95 and above indicating good fit and a RMSEA of .05-.08 and a CFI/TLI of .90-.95 indicating acceptable fit (Hu & Bentler, 1995).

First, a mediation path model was tested on the link between social problem-solving at the 3-months assessment and suicidal ideation at the 9-months assessment, with two parallel mediators namely thwarted belongingness and perceived burdensomeness. Baseline variables of social problem-solving, suicidal ideation, thwarted belongingness and perceived burdensomeness were controlled, as well as race. Then, a multiple-group model was estimated, to investigate the differences in mediating paths between the two treatment groups. Two nested models were tested, with constraints on the mediation pathways being first the same and then different across groups. The chi-square test was used to compare the model fits of the two nested models. If the fit of the unconstrained model is better compared to the constrained model, it indicates the parameter estimates of the mediating pathway differed significantly across groups. The indirect effects were then analyzed using the bootstrap sampling method (Preacher & Hayes, 2007) in both groups.

Results

Descriptive statistics and bivariate correlations are presented in Table 2. First, a mediation path model was estimated with the whole sample. Figure 2 presents the parameter estimates. The model yielded an acceptable fit, χ2(22) = 37.31, p = .02; RMSEA = .068 (CI.90 = .026, .165); CFI =. 930; TLI = .904. Social problem-solving at 3 months significantly predicted lower thwarted belongingness (β = −.28, SE = .08, t = −3.56, p < .001) and perceived burdensomeness (β = −.31, SE = .08, t = −3.89, p < .001) at 6 months. Thwarted belongingness at 6 months was not associated with suicidal ideation at 9 months (β = .06, SE = .11, t = .57, p =.58). In contrast, perceived burdensomeness at 6 months predicted suicidal ideation at 9 months (β = .38, SE = .11, t = 3.53, p <.001). The direct effects from social problem-solving at 3 months to suicidal ideation at 9 months were not significant (β = .002, SE = .09, t = .02, p =.99).

Table 2.

Descriptive Statistics and Bivariate Correlations of Study Variables

1 2 3 4 5 6 7 8 9 10 11 12
1. Treatment
2. Sex −.04
3. Race: White −.01 .06
4. Race: Other .03 .03 −.44**
5. Suicidal ideation baseline .05 −.14 .05 .02
6. Suicidal ideation 9 month −.09 .09 .19* −.09 .10
7. Social problem solving baseline −.08 .04 −.05 −.08 −.01 −.07
8. Social problem solving 3 month .00 .13 .02 .01 .09 −.16 .66**
9. Burdensomeness baseline .04 −.16 .12 −.12 −.02 .27** −.38** −.30**
10. Burdensomeness 6 month .04 .02 .10 −.22* −.04 .40** −.15 −.40** .29**
11. Belongingness 6 month .05 −.15 −.06 −.11 −.02 .13 −.22** −.17 .53** .10
12. Belongingnes −.02 −.12 −.04 −.16 −.05 .28** −.03 −.35** .16 .66** 24**
N 150 150 150 150 150 129 150 131 150 129 150 129
Mean .50 .59 .39 .23 22.91 5.45 11.09 11.75 3.96 3.21 4.12 3.40
SD .50 .49 .49 .42 4.84 5.89 3.05 2.91 1.08 1.20 1.14 1.40
Minimum .00 .00 .00 .00 12.00 .00 2.20 4.00 1.53 1.40 1.00 1.00
Maximum 1.00 1.00 1.00 1.00 38.00 23.00 18.20 19.40 6.60 6.60 6.50 7.00
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Note. Treatment: CTSP+TAU=1, TAU = 0. CTSP=Cognitive Therapy for Suicide Prevention, TAU = Treatment as Usual. Race: White (race being White): White =1, Black and other minority races = 0. Race: Other (race being other minority races): other minority races = 1, White and Black =0. Sex: male = 1, female = 0.

*

p < .05

**

p < .01

***

p < .001.

Second, a multiple-group model was estimated. Figure 3 presents the parameter estimates. The final model yielded an acceptable fit, χ2(44) = 59.01, p = .06; RMSEA = .067 (CI.90 = .000, .109); CFI =. 936; TLI = .912. Social problem-solving at 3 months significantly predicted lower thwarted belongingness (CTSP: β = −.29, SE = .12, t = −2.50, p < .05; TAU: β = −.27, SE = .11, t = −2.56, p < .05) and perceived burdensomeness (CTSP: β = −.37, SE = .11, t = −3.32, p <.001; TAU: β = −.26, SE = .11, t = −2.28, p < .05) at 6 months in both groups. Thwarted belongingness at 6 months was not associated with suicidal ideation at 9 months (CTSP: β = −.07, SE = .12, t = −0.54, p = .59; TAU: β = 0.18, SE = .17, t = 1.09, p = .28). Perceived burdensomeness at 6 months predicted suicidal ideation at 9 months only among youth in the CTSP group (β = .78, SE = .11, t = 7.22, p < .001), but not the TAU group (B = .05, SE = .17, t = 0.29, p = .77). The paths for direct effects were not significant in both groups (CTSP: B = .16, SE = 0.11, t = 1.52, p = .13; TAU: β = −.12, SE = .13, t = −.95, p = .35). The multiple-group comparison was then performed to investigate the differences in mediating paths between the two treatment groups. The path model was estimated first freely, then each individual path involved in mediation (from social problem-solving at 3 months to thwarted belongingness and perceived burdensomeness at 6 months then to suicidal ideation at 9 months) was constrained step-by-step, to test the differences in model fit. Only the path from perceived burdensomeness at the 6-month assessment point to suicidal ideation at the 9-month assessment point yielded a significant between-group difference, χ2(1) = 9.79, p = .002, signaling a significant between-group difference between the two treatment groups.

Figure 3.

Figure 3.

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Results of parameter estimates for the moderated mediation model. Note. Standardized coefficients are shown in the figure. Coefficients: CTSP/TAU, coefficients shown on the left are for the CTSP condition, and those shown on the right are for the TAU condition. CTSP=Cognitive Therapy for Suicide Prevention, TAU = Treatment as Usual. For visual simplicity, the parameter estimates for stability (i.e., the association between baseline and post-baseline variables) are not shown graphically in the model.

* p < .05, *** p < .001

Further, we tested the parallel mediation model in both groups with bootstrapping procedures. Significant mediation was found in the path from social problem-solving at 3 months to suicidal ideation at 9 months through perceived burdensomeness at 6 months, only among youth in the CTSP group (B = −0.52, SE = 0.19, t = −2.79, p = .005, CI.90 = −0.83, −0.21), but not the TAU group (B = −0.03, SE = 0.10, t = −0.29, p = .77, CI.90 = −0.20, 0.14).

Social problem-solving showed significant stability from baseline to 3 months (CTSP: β = 0.66, SE = 0.07, t = 9.51, p < .001; TAU: β = 0.63, SE = 0.07, t = 8.65, p < .001). Thwarted belongingness and perceived burdensomeness showed stability over 6 months only in the TAU group (thwarted belongingness: β = 0.30, SE = 0.09, t = 3.24, p < .001; perceived burdensomeness: β = 0.26, SE = 0.10, t = 2.61, p < .01), but not in the CTSP group (thwarted belongingness: β = 0.18, SE = 0.10, t = 1.81, p = .07; perceived burdensomeness: β = 0.16, SE = 0.09, t = 1.62, p = .10). Suicidal ideation was not stable from baseline to 9 months (CTSP: B = 0.16, SE = .09, t = 1.80, p = .07; TAU: B = 0.12, SE = 0.12, t = 1.00, p = .32).

To understand the longitudinal change of social problem-solving following treatment, a latent growth curve analysis was performed to model the trajectory of social problem-solving assessed at baseline, 3, 6, and 9 months post-baseline. The direct effects of treatment on the change of social problem-solving was examined as well. Since this manuscript focused on the moderating effects of treatment condition, the modeling of the direct effects of treatment was beyond its scope, however, we included this information in the supplemental material. Findings of the supplemental analyses showed social problem-solving improved significantly over time in both treatment conditions.

Discussion

The current study investigated a longitudinal moderated mediation model with perceived burdensomeness and thwarted belongingness as the parallel mediators linking social problem-solving and suicidal ideation among a sample of homeless youth experiencing suicidal ideation. The moderating effects of CTSP on the mediation pathways were also examined. Our findings showed that the mediation link between social problem-solving, perceived burdensomeness, and suicidal ideation was only detected among individuals participating in the CTSP condition but not the TAU condition. As social problem-solving improved over time as indicated by the supplemental analyses, these findings further suggest that CTSP has the potential to transmit the protective effects due to improved social problem-solving to reduce suicidal ideation, through the mediating effects of perceived burdensomeness. In contrast, increased social problem-solving does not contribute to reduced suicidal ideation among individuals participating in the TAU condition.

Consistent with our hypothesis, findings showed high levels of social problem-solving at 3 months post-baseline was associated with low levels of perceived burdensomeness at 6 months, which was subsequently associated with low levels of suicidal ideation at 9 months in the CTSP condition. This mediation was not found in the TAU condition as perceived burdensomeness at 6 months was not significantly associated with suicidal ideation at 9 months. One possible explanation is that participation in CTSP creates a new cognitive state that intensifies the association between social problem-solving and perceived burdensomeness, which in turn, effectively disrupts the stability of perceived burdensomeness and its negative effects on suicidal ideation. Indeed, our findings support this possibility by showing that the stability of perceived burdensomeness from baseline to 6-months post-baseline was only observed among youth in the TAU condition but not in the CTSP condition. Another possibility for this finding is that the association between perceived burdensomeness and suicidal ideation may be influenced by an extraneous variable or mechanism that is prone to the influence of CTSP, such that the strength of the link between perceived burdensomeness and suicidal ideation varies as a function of this extraneous factor, and in turn, is influenced by the effects of CTSP. In contrast, TAU shows no effects on this extraneous factor. Consequently, variations in perceived burdensome do not relate to variations in suicidal ideation in the TAU condition.

Research identifies interpersonal factors that moderate the association between perceived burdensomeness and suicide ideation. For example, among a sample of Asian American college students, Wong and colleagues (2011) found that the association between perceived burdensomeness and suicidal ideation varied depending on the levels of interdependent self-construal, a concept referring to building one’s self-concept based on relationships with others. More specifically, the researchers found that perceived burdensomeness was positively related to suicidal ideation in the context of relatively low interdependent self-construal, but this association was not found among participants reporting relatively high interdependent self-construal. In the case of homeless youth, interpersonal moderators prone to the effects of CTSP may exist to differentiate the association between perceived burdensomeness and suicidal ideation. Identifying such moderators is critical to single out and intensify active therapeutic components that facilitate more efficient suicide prevention for homeless youth (Kraemer, Wilson, Fairburn, & Agras, 2002).

Contrary to our hypothesis, thwarted belongingness was not a significant mediator in either the CTSP or TAU condition. Although not supporting the underlying propositions of the Interpersonal Theory of Suicide, this finding is consistent with recent research that indicates that perceived burdensomeness serves as a more robust predictor in understanding suicidal ideation (Chu et al., 2018). Compared to their housed peers, homeless youth, who often leave their home because of intense family conflicts or abusive relationships, typically experience social isolation (Rew, 2000), and may become habituated to this feeling over time. As a result, thwarted belongingness may become less pernicious in explaining suicidal ideation for this population. This finding suggests that the unique ecological environment and associated characteristics of targeted populations should be considered for the application of the Interpersonal Theory of Suicide. Overall, findings from the current study generally support the propositions of the Diathesis-Stress Model and the Interpersonal Theory of Suicide by showing the dynamic and prospective association between social problem-solving and suicidal ideation through the effects of perceive burdensomeness.

Our findings should be considered in light of several limitations. First, the current study used a convenience sample of homeless youth accessing a drop-in center. Youth who are willing to seek services and supports through a drop-in center may be more motivated to make changes in their current life situation and may differ from youth who remain disconnected from services. Thus, the findings of this study might not generalize to other homeless youth. Moreover, homeless youth may encounter extremely stressful life situations associated with living on the streets (Gaetz 2004; Hammer et al. 2002; Kidd 2006), which is not typically observed among non-homeless peers. Research suggests that those who are exposed to higher risk before interventions are likely to benefit more from interventions (Tein, Sandler, MacKinnon, & Wolchik, 2004). Consequently, homeless youth may respond to intervention in a different way compared to their non-homeless peers. Therefore, caution is needed when generalizing the findings of the current research to youth at risk of suicide but who are not homeless. Second, although our work shows the value of preventive intervention with a high-risk population, our findings may not generalize to treatment seeking populations, as treatment seeking clients usually have higher motivation to change which may generate different treatment outcomes. Third, this study did not take into account how contact with therapists might influence perceived burdensomeness and thwarted belongingness, as these two variables may be influenced by interpersonal interaction with therapists. Fourth, the treatment as usual provided by the drop-in center therapists was not recorded and coded. Future research should code the therapy techniques used in TAU in order to strengthen the conclusions regarding CTSP’s effectiveness. Another limitation is this study’s reliance on self-report measures. Using behavioral measures (such as daily diaries) could create extra burden to this population and increase the difficulty for recruitment and retention. However, future research can complement self-report measures with behavioral measures to strengthen the findings of suicide research (Nock et al., 2010). Beyond these limitations, to our knowledge, this is the first study that provides evidence to support the potential of CTSP in producing positive change in suicidal ideation through inducing a new cognitive and psychological state that enhances the association of protective factors with suicide risk in a sample at high risk of suicide. Specifically, participation in CTSP facilitates the transmission of the protective effects due to improved social problem-solving to reduce suicidal ideation, through the mediating effects of perceived burdensomeness. Significant moderating effects of participating in CTSP were observed although youth attended relatively low number of sessions. It is possible that the first few CTSP sessions that are concerned with the development of the crisis plan and individuals’ core beliefs associated with suicide are particularly helpful for youth (author masked). Most importantly, expanding on prior research supporting CTSP in clinical samples (Brown et al., 2005; Stanley et al., 2009), our study provides evidence to support the efficacy of CTSP in a community-based sample not seeking treatment for depression or suicide. Through screening for suicide ideation within a high-risk population, CTSP has the potential to reach a wider population and potentially reduce the public health burden incurred by suicide.

Supplementary Material

1

Highlights.

  • Cognitive therapy strengthens the pathways to reduce suicidal ideation.

  • Perceived burdensomeness mediates the positive effects of social problem-solving.

  • Cognitive therapy enhances the positive effects of social problem-solving.

Acknowledgements:

This work was supported by NIDA Grant # R34DA037845 to the last author.

Footnotes

The authors declare that they have no conflict of interest.

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