Arts, Faculty of
Psychology, Department of
DSpace
UBCV
Pachkowski, Mikayla
Doctor of Philosophy - PhD
University of British Columbia
Key to suicide prevention is the ability to cope with and safely manage suicidal ideation. However, despite an extensive literature on coping with distress, very little research has examined how people cope with suicidal ideation specifically (henceforth referred to as suicide-specific coping; SSC). Thus, this dissertation aimed to address foundational questions about SSC. In Study 1, I examined the frequency with which different SSC responses were used, the perceived impact of these responses on ideation, and the cross-sectional associations between SSC and suicidal ideation and attempts. This study consisted of a detailed semi-structured interview and self-report measures assessing SSC and suicidal ideation administered to 102 undergraduates with a lifetime history of suicidal ideation. In Study 2, I examined longitudinally how SSC predicted subsequent suicidal ideation over the next week (and vice versa). This study employed a two-wave longitudinal design and used self-report measures to assess SSC and suicidal ideation in 400 North American adults who reported recent suicidal ideation. Results from Study 1 identified SSC responses that were more frequent (e.g., withdrawing from others), less frequent (e.g., going to the hospital), more helpful (e.g., finding someone understanding), and more harmful (e.g., withdrawing from others). Adaptive and Maladaptive SSC scales demonstrated minimal to moderate correlations with suicidal ideation and history of attempts. Study 2 found that more frequent maladaptive SSC predicted more intense next week suicidal ideation, and greater confidence and knowledge in SSC predicted less intense next week suicidal ideation. Overall, results from this dissertation provide descriptive information regarding frequency and perceived impact of SSC. Findings also highlight the potential adverse impacts of maladaptive SSC responses on next week suicidal ideation and the potential positive impact of knowledge and confidence in SSC on next week suicidal ideation. Research and clinical implications are discussed, along with limitations and future directions. Findings provide useful information to guide future research, support clinicians working with suicidal individuals, and may also help inform large-scale public suicide prevention efforts designed to facilitate effective coping with suicidal ideation.
COPING WITH SUICIDAL IDEATION: A CROSS-SECTIONAL AND LONGITUDINAL EXAMINATION by Mikayla Pachkowski MA, The University of British Columbia, 2020 BA (Hons), The University of British Columbia, 2017 A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Psychology) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) August 2025 © Mikayla Pachkowski, 2025 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled: _Coping with suicidal ideation: A cross-sectional and longitudinal examination _________________ submitted by __Mikayla Pachkowski_______ in partial fulfilment of the requirements for the degree of _Doctor of Philosophy_______________________________________________________ in _Psychology_______________________________________________________________ Examining Committee: E. David Klonsky, Professor, Psychology, University of British Columbia Supervisor Joelle LeMoult, Associate Professor, Psychology, University of British Columbia Supervisory Committee Member Luke Clark, Professor, Psychology, University of British Columbia Supervisory Committee Member Noah Silverberg, Associate Professor, Psychology, University of British Columbia University Examiner Daniel Cox, Professor, Counselling Psychology, University of British Columbia University Examiner Raymond Tucker, Associate Professor, Psychology, Louisiana State University External Examiner iii Abstract Key to suicide prevention is the ability to cope with and safely manage suicidal ideation. However, despite an extensive literature on coping with distress, very little research has examined how people cope with suicidal ideation specifically (henceforth referred to as suicide-specific coping; SSC). Thus, this dissertation aimed to address foundational questions about SSC. In Study 1, I examined the frequency with which different SSC responses were used, the perceived impact of these responses on ideation, and the cross-sectional associations between SSC and suicidal ideation and attempts. This study consisted of a detailed semi-structured interview and self-report measures assessing SSC and suicidal ideation administered to 102 undergraduates with a lifetime history of suicidal ideation. In Study 2, I examined longitudinally how SSC predicted subsequent suicidal ideation over the next week (and vice versa). This study employed a two-wave longitudinal design and used self-report measures to assess SSC and suicidal ideation in 400 North American adults who reported recent suicidal ideation. Results from Study 1 identified SSC responses that were more frequent (e.g., withdrawing from others), less frequent (e.g., going to the hospital), more helpful (e.g., finding someone understanding), and more harmful (e.g., withdrawing from others). Adaptive and Maladaptive SSC scales demonstrated minimal to moderate correlations with suicidal ideation and history of attempts. Study 2 found that more frequent maladaptive SSC predicted more intense next week suicidal ideation, and greater confidence and knowledge in SSC predicted less intense next week suicidal ideation. Overall, results from this dissertation provide descriptive information regarding frequency and perceived impact of SSC. Findings also highlight the potential adverse impacts of maladaptive SSC responses on next week suicidal ideation and the potential positive impact of knowledge and confidence in SSC on next week suicidal ideation. Research and clinical iv implications are discussed, along with limitations and future directions. Findings provide useful information to guide future research, support clinicians working with suicidal individuals, and may also help inform large-scale public suicide prevention efforts designed to facilitate effective coping with suicidal ideation. v Lay Summary How do people cope with suicidal thoughts? This is an important question, as coping skills are central to interventions for suicidal individuals. However, little research has explored this topic. This dissertation examined how adults cope with suicidal thoughts across two studies. Study 1 involved interviewing 102 adults about the frequency and perceived effectiveness of different coping responses. Study 2 examined whether coping responses predicted suicidal thoughts during the subsequent week, and vice versa. Findings suggested that a wide range of coping responses are used, with most considered helpful. However, results also suggested that some maladaptive coping responses are relatively common and may lead to more intense suicidal thoughts over time. Finally, having greater knowledge and confidence in oneâs coping was found to predict reductions in future suicidal thoughts. Overall, this research offers important insights into coping with suicidal thoughts and may have meaningful implications for future research and clinical practice. vi Preface This dissertation represents original and independent work conducted by myself (Mikayla Pachkowski) under the supervision of Dr. E. David Klonsky, the principal investigator of the Personality, Emotion, and Behavior Lab (PEBL) within the Department of Psychology at the University of British Columbia. I devised the research questions, designed the studies, collected the data, analyzed results, and wrote this dissertation. Dr. Klonsky provided supervision, feedback, and edits throughout this process. The use of Generative Artificial Intelligence in this dissertation was approved by Dr. Klonsky and was limited to the use of ChatGPT by OpenAI in the final editing process to assist in checking sentences for clarity. Both studies included in this dissertation were approved by the University of British Columbia Behavioural Research Ethics Board (H18-01262; H23-02047). Data from Study 2 of this dissertation has been published in Current Psychology: Manuel, D.E., Pachkowski, M.C., & Klonsky, E.D. (2025). The Tripartite Meaning Model and Suicidal Desire: Differential Associations of Purpose, Mattering, and Coherence in Undergraduate and Community Samples. The manuscript utilized a measure from Study 2âs dataset (Meaningfulness in life) to examine research questions unrelated to the research reported on in this dissertation. The idea for this manuscript, data analysis, and writing was completed by David Manuel. I (Mikayla Pachkowski) collected data for one of the samples in the manuscript and assisted in revising the manuscript. Dr. Klonsky assisted in providing feedback through the data analytic process and in revising the manuscript. vii Table of Contents Abstract .......................................................................................................................................... iii Lay Summary .................................................................................................................................. v Preface ........................................................................................................................................... vi Table of Contents ......................................................................................................................... vii List of Tables ................................................................................................................................ xii List of Figures ............................................................................................................................. xiii Acknowledgements ...................................................................................................................... xiv Dedication.................................................................................................................................... xvi Introduction .................................................................................................................................... 1 Overview ..................................................................................................................................... 1 Conceptualizing Coping ............................................................................................................. 3 Intentional versus Automatic Coping Responses ................................................................................... 4 Categorizing Coping: Higher Order and Lower Order Coping ............................................................. 5 Adaptive and Maladaptive Coping......................................................................................................... 6 Coping Flexibility .................................................................................................................................. 9 Coping and Emotion Regulation .......................................................................................................... 10 Quality versus Quantity of Coping Responses..................................................................................... 11 Measurement of Coping ....................................................................................................................... 12 Summary: Conceptualizing and Measuring Coping ............................................................................ 14 General Coping and Suicide-Related Variables .................................................................... 14 Emotion-focused and Avoidance Coping ............................................................................................ 15 Problem-solving Coping ...................................................................................................................... 16 viii Longitudinal Studies ............................................................................................................................ 17 Summary: General Coping and Suicide-Related Variables ................................................................. 18 Suicide-Specific Coping (SSC) ................................................................................................ 18 Knowledge and Confidence in SSC ..................................................................................................... 20 Individual SSC Responses ................................................................................................................... 22 Limitations of Existing Research ............................................................................................ 26 Current Dissertation ................................................................................................................ 30 Study 1 Research Questions ................................................................................................................. 32 Study 2 Research Questions ................................................................................................................. 34 Study 1 .......................................................................................................................................... 39 Study 1 Methods ....................................................................................................................... 39 Participants and Procedure ................................................................................................................... 39 Measures .............................................................................................................................................. 42 Data Analytic Plan ............................................................................................................................... 50 Power analysis ...................................................................................................................................... 52 Study 1 Results ......................................................................................................................... 53 Preliminary Considerations .................................................................................................................. 53 Data Preparation ................................................................................................................................... 53 Preliminary Analyses ........................................................................................................................... 55 Research Question 1 (Study 1): Frequency of SSC Responses ........................................................... 59 Research Question 2 (Study 1): Perceived Impact of SSC Responses ................................................ 62 Research Question 3 (Study 1): Association of SSC with Suicidal Ideation and Attempts ................ 69 Robustness Checks ................................................................................................................... 72 ix Study 2 .......................................................................................................................................... 74 Study 2 Methods ....................................................................................................................... 74 Procedure.............................................................................................................................................. 74 Participants ........................................................................................................................................... 76 Measures .............................................................................................................................................. 78 Data Analytic Plan ............................................................................................................................... 91 Power Analysis..................................................................................................................................... 93 Study 2 Results ......................................................................................................................... 94 Preliminary Considerations .................................................................................................................. 94 Data Preparation ................................................................................................................................... 95 Preliminary Analyses ........................................................................................................................... 97 Research Question 1 (Study 2): Relationship between SSC and Suicidal Ideation ........................... 106 Research Question 2 (Study 2): Coping-related Covariate Analyses ................................................ 115 Research Question 3 (Study 2): Suicide Theory-informed Covariate Analyses ................................ 118 Robustness Checks ................................................................................................................. 121 Discussion................................................................................................................................... 123 Overview of Findings ............................................................................................................. 124 Individual Suicide-Specific Coping (SSC) Responses ......................................................... 125 Reasons for living .............................................................................................................................. 125 Withdrawing from others ................................................................................................................... 126 Fantasizing about dying ..................................................................................................................... 127 Nonsuicidal self-injury (NSSI) .......................................................................................................... 129 Means safety....................................................................................................................................... 130 x Risk-taking behaviors......................................................................................................................... 131 Finding someone understanding ........................................................................................................ 132 Exercise/recreational physical activity ............................................................................................... 133 Crisis Center ....................................................................................................................................... 133 Grounding skills ................................................................................................................................. 135 Using a mobile app to cope ................................................................................................................ 135 Dimensions of SSC and Suicidal Ideation ............................................................................ 136 Cross-Sectional Relationship of SSC Dimensions and Suicidal Ideation .......................................... 136 Longitudinal Relationship of SSC Dimensions and Suicidal Ideation .............................................. 138 Differences in SSC across Demographic and Clinical Characteristics ............................. 140 Key Implications ..................................................................................................................... 142 Individuality of SSC ........................................................................................................................... 142 Psychoeducation of SSC .................................................................................................................... 142 Maladaptive SSC predicts Suicidal Ideation ...................................................................................... 143 Knowledge and Confidence in SSC ................................................................................................... 144 Limitations .............................................................................................................................. 145 Future Directions.................................................................................................................... 150 Conclusion ............................................................................................................................... 151 References .................................................................................................................................. 152 Appendices .................................................................................................................................. 177 Appendix A: Study 1 Semi-Structured Interview of Suicide-Specific Coping ................. 177 Appendix B: Study 2 Self-report Measure of Suicide-Specific Coping ............................. 179 Appendix C: Rationale for inclusion of suicide-specific coping items in Study 2 ............ 181 Appendix D: Suicide-Related Coping Scale (SRCS; Stanley et al., 2017) ......................... 184 xi Appendix E: Study 2 multiple groups cross-lagged panel model ...................................... 186 Table E1 ............................................................................................................................................. 188 Appendix F: Study 2 confidence intervals for cross-lagged panel model analyses .......... 190 Table F1 ............................................................................................................................................. 190 xii List of Tables TABLE 1. Study 1 demographic characteristicsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.41 TABLE 2. Study 1 clinical characteristicsâ¦â¦â¦â¦.â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.56 TABLE 3. Descriptive statistics for Study 1 key variablesâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.57 TABLE 4. Study 1 Research Question 1: Frequency of suicide-specific coping itemsâ¦â¦â¦â¦â¦â¦.â¦â¦â¦â¦â¦.61 TABLE 5. Study 1 Research Question 2: Perceived impact of suicide-specific copingâ¦â¦â¦..â¦â¦..â¦â¦â¦â¦â¦.64 TABLE 6. Study 1 Research Question 2: Perceived impact of suicide-specific coping on overall ideationâ¦â¦â¦..67 TABLE 7. Study 1 Research Question 2: Perceived impact of suicide-specific coping in percentagesâ¦â¦â¦â¦â¦.69 TABLE 8. Study 1 Research Question 3: Correlations between suicide-specific coping items and current suicidal ideation, worst-point ideation, and suicide attempt historyâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.70 TABLE 9. Study 1 Research Question 3: Correlations between dimensions of suicide specific coping and current suicidal ideation, worst-point ideation, and suicide attempt historyâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.71 TABLE 10. Study 2 demographic characteristicsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.....â¦...77 TABLE 11. Factor Loadings from Exploratory Factor Analysis of Beck Scale for Suicide ideation in Study 2..â¦..83 TABLE 12. Factor Loadings for Exploratory Factor Analysis of Brief COPEâ¦â¦â¦â¦.â¦â¦â¦..â¦â¦â¦â¦â¦â¦....87 TABLE 13. Study 2 clinical characteristicsâ¦â¦â¦â¦â¦â¦...â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.98 TABLE 14. Descriptive statistics for Study 2 key variables at time 1 and time 2.................................................â¦101 TABLE 15. Correlations between Study 2 variables at time 1, time 2, and test-retestâ¦â¦â¦â¦â¦â¦â¦â¦â¦.....â¦.102 TABLE 16. Study 2 frequency of suicide-specific coping items used in the past weekâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦105 TABLE 17. CLPM results for all dimensions of suicide-specific coping and suicidal ideationâ¦..â¦â¦...â¦â¦â¦..107 TABLE 18. CLPM results for individual suicide-specific coping items and suicidal ideation.â¦..â¦â¦â¦â¦â¦â¦..114 xiii List of Figures FIGURE 1. CLPM for Frequency of Maladaptive suicide-specific coping and suicidal ideationâ¦â¦â¦â¦â¦â¦â¦108 FIGURE 2. CLPM for Knowledge/Confidence in suicide-specific coping and suicidal ideationâ¦â¦â¦â¦â¦â¦â¦109 FIGURE 3. CLPM of relationship between suicide-specific coping dimensions (Maladaptive Frequency and Knowledge/Confidence) and suicidal ideationâ¦...â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦116 xiv Acknowledgements First and foremost, I am deeply grateful to my supervisor, Dr. E. David Klonsky. Thank you for your mentorship, support and confidence, and encouragement over these past seven years. Working with you has inspired me to be a better scientist, better clinician, and a better person. I will forever be grateful that I had the privilege of completing my graduate training under your supervision. I would also like to thank my committee members, Dr. Luke Clark and Dr. Joelle LeMoult, who provided such valuable and thoughtful feedback on my work over these years. Thank you also to the current and past PEBLab members, who have been a source of support, advice, and assisted in this work. A special thanks is owed to my fellow graduate students, residency cohort, and research friends, in particular, Kirsten Christensen, Michelle Hunsche, Mario Ferrari, Ruth Vanstone, and Chelsea Wood-Ross. So much of the work for this dissertation was completed alongside each of you. Your friendship, wise research (and life) advice, and support have been an invaluable part of my graduate school journey. Also, to my cat, Kaprije, who unwittingly supervised many hours of work and writing. I am incredibly grateful to my family. Thank you to my parents, Branca and Bruce Pachkowski, my siblings, Michael, Nicole, Madison, Andrew, Maclean, and Miranda, my nephew and nieces Emmett, Charlotte, and Emma, my in-laws, and my late grandparents for all your love, support, and patience throughout these years. I would not be the person I am today, or completing this degree, without each of you. Thank you also to my friends, Sarah Moore and Brooke McDonald, for being by my side all these years. To my biggest supporter and love of my life, my husband Adri Khalis Bin Abdul Karim. This dissertation and degree would not have been possible if not for your endless love, support, xv and encouragement. Whether in the form of the numerous meals you prepared me while I worked, your continued belief in me even when deadlines did not seem possible, or reminding me of what is most important in life; I am so grateful to be your partner. You will always be the best thing that happened to me in graduate school, and the best part of my life. Finally, I would like to express my sincerest gratitude to all the participants who took part in my studies, as well as to the clients Iâve worked with over these years who have lived with suicidal thoughts. You are the inspiration for this work. My hope is that this research helps to bring greater understanding to others who are suicidal, reminding them that they are not alone. xvi Dedication To Lavonne Sammut 1 Introduction Overview Suicide is a leading cause of death worldwide, with recent estimates suggesting that over 720,000 people die by suicide each year (World Health Organization (WHO), 2025). In Canada, it is estimated that more than 12 Canadians die by suicide each day (Statistics Canada, 2023). For each death by suicide, estimates suggest that 25 non-lethal suicide attempts are made (WHO, 2019). Despite the development of several evidence-based interventions for suicidal individuals over the past three decades, including Dialectical Behavior Therapy (DBT; Linehan, 1993), Cognitive Therapy for Suicide Prevention (Brown et al., 2005), and crisis interventions and hotlines (Gould et al., 2021; Stanley & Brown, 2012), a recent meta-analysis suggests that interventions for suicidal individuals show limited impact (Fox et al., 2020). There remains an urgent need for improved understanding of managing and treating suicide risk. One promising avenue in advancing suicide prevention lies in understanding how individuals safely cope with and manage their suicidal ideation. Suicide-specific coping (i.e., how people cope with their suicidal thoughts, as opposed to how they cope in general; SSC) is increasingly emphasized within suicide prevention approaches and interventions. For example, a recently published self-help manual explicitly focuses on improving coping with suicidal ideation (Gordon, 2021), coping responses to manage suicidal crises are easily accessible through online sources such as the Canadian Association for Suicide Prevention, and coping suggestions for managing suicidal thoughts can be found on social media platforms such as Facebook and Instagram. There is emerging empirical work on how individuals cope with their suicidal thoughts that also supports a connection between the ability to cope with suicidal 2 thoughts and oneâs suicide risk. For example, interventions aimed at enhancing coping responses to manage suicidal crises are found to help lower future risk of suicide attempts (Stanley & Brown, 2012), and the perceived ability to control oneâs suicidal thoughts has been associated with a decreased likelihood of attempting suicide (Nock et al., 2018). More recent research suggests that SSC predicts relevant outcomes, including future suicidal ideation, suicide attempts, and psychiatric hospitalization (Interian et al., 2021; Stanley et al., 2021). Although the recent expansion of research and clinical application of coping with suicidal ideation is encouraging, this research area is relatively new, and important knowledge gaps remain. First, although a variety of coping responses are widely suggested by suicide prevention organizations and incorporated into therapies for suicidal individuals, a detailed examination of how often these coping responses are actually used and their perceived impact on suicidal thoughts has yet to be conducted. As such, the frequency with which individuals use various SSC responses as well as the perceived helpfulness (and harmfulness) of these coping responses is largely unknown. Second, longitudinal research on SSC has focused on understanding the relationship between common adaptive coping responses (e.g., socializing, mindfulness, distraction) and future suicidal ideation, and has yet to examine the relationship between maladaptive coping responses (e.g., nonsuicidal self-injury; NSSI, substance use) and future suicidal ideation (Stanley et al., 2021). The examination of maladaptive SSC responses is important because research provides robust evidence for the co-occurrence of general maladaptive coping responses and suicidal ideation (Herzog et al., 2022; Klonsky, 2007). This dissertation consists of two studies with the overarching aim of advancing understanding of SSC. Findings from this dissertation carry implications for researchers seeking to advance understanding of coping and suicide prevention, for health care providers working 3 with suicidal patients, for large-scale suicide prevention strategies, and for suicidal individuals who wish to better understand how to cope with their suicidal ideation. The organization of this introduction is as follows. First, I discuss influential conceptualizations of general coping in the literature. Second, I review the existing body of research on general coping and suicide-related variables. Third, I discuss the existing literature on coping with suicidal ideation specifically. Fourth, I outline key limitations of the reviewed literature. Finally, I provide an overview of the current dissertation and its research aims. Conceptualizing Coping Although a variety of definitions and conceptualizations of coping exist (Carver & Connor-Smith, 2010), the most widely used definition comes from Lazarus and Folkman who define coping as âconstantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the personâ (1984, p. 141). According to this definition, coping may be thought of as cognitions or behaviors that a person engages in with the aim of managing a stressor. In applying this definition to the current dissertation, which is interested in how individuals cope when feeling suicidal, SSC can be defined as thoughts and actions taken to manage a specific stressor: suicidal thoughts. Additional considerations to conceptualizing coping have been raised in the literature, including: whether coping should only entail intentional coping responses or also include automatic responses to stressors, how to categorize different coping approaches, what it means for coping responses to be adaptive or maladaptive, coping flexibility, differences between 4 coping and emotion regulation, quality versus quantity of coping responses, and the measurement of coping. These considerations are reviewed below. Intentional versus Automatic Coping Responses An important consideration in defining coping concerns whether the thoughts or actions an individual engages in to manage a stressor are engaged in deliberately (Compas et al., 2001). Although Lazarus and Folkman only consider coping as thoughts or actions that are effortful and engaged in with purpose (Lazarus & Folkman, 1984), a more recent conceptualization of coping suggests that coping is broader than this and includes both effortful and automatic/involuntary responses to a stressor (Skinner & Zimmer-Gembeck, 2007). This newer conceptualization recognizes that the distinction between thoughts or actions that are taken with intention versus those that occur as an automatic process is not always clear. For example, although a certain coping response may first be used as an intentional and effortful strategy, that coping response can become automatic with time and practice (Barnicot & Crawford, 2019; Carver & Connor-Smith, 2010). Including automatic or involuntary responses in defining coping may be particularly relevant when considering SSC. One recent study of 40 clients with borderline personality disorder who had engaged in Dialectical Behavior Therapy (DBT), a therapy which specifically targets suicidal ideation, examined reported barriers to using coping skills (Barnicot & Crawford, 2019). A key finding from this study was that for nearly half of the participants, the automatization of skills was described as one important way to overcome barriers to using skills in the first place. This suggests that excluding automatic coping responses may result in the 5 exclusion of coping practices that have become particularly effective for individuals at greater risk for suicidal ideation. Another reason to include automatic responses in the conceptualization of SSC is that certain coping responses may occur as a natural reaction to suicidal thoughts. For example, consideration of future consequences is a common reaction to contemplating any potential behavior (Strathman et al., 1994), and thus, in contemplating suicide, an individual may consider the consequences of acting on their suicidal thoughts. Indeed, one study examining coping responses for managing suicidal ideation found that thinking about consequences to acting on suicidal thoughts was among the most frequently reported coping responses (Alexander et al., 2009). In other words, the distinction between intentional versus automatic coping responses is not entirely clear. In order to capture a more comprehensive understanding of coping with suicidal ideation, this dissertation uses the definition provided by Lazarus and Folkman but extends it to include thoughts and actions taken to manage suicidal ideation that are engaged in either intentionally or automatically. Categorizing Coping: Higher Order and Lower Order Coping Another complication in the field of coping involves how to categorize specific coping responses. Lazarus and Folkman (1984) originally suggested that coping serves two main functions: 1) changing or altering the source of distress or the problem, and 2) regulating oneâs emotional response to a stressor. Based on this understanding, they proposed that depending on the function, coping responses should be conceptualized as problem-focused or emotion-focused coping. 6 These overarching categories of coping responses are referred to in the literature as higher-order families of coping (Compas et al., 2001; Skinner et al., 2003), and each higher-order family of coping encompasses a range of lower-order coping responses. Lower-order coping refers to the actual specific coping responses used by an individual (e.g., planning, decision making, repairs to a relationship; Skinner & Zimmer-Gembeck, 2007), with many lower-order coping responses corresponding to one overarching higher-order coping family. Although Lazarus and Folkmanâs categorization of problem versus emotion-focused coping is fundamental to the contemporary understanding and conceptualization of coping, disagreements with this framework have been raised. Research has since expanded these broad categories of coping styles (i.e., problem-focused and emotion-focused coping) to include additional categories, such as support-seeking, escape, distraction, cognitive restructuring, rumination, helplessness, social withdrawal, emotion regulation, information-seeking, and negotiation, among many others (Skinner & Zimmer-Gembeck, 2007). In fact, a review of the literature on coping identified over 400 different higher-order families of coping (Skinner et al., 2003). Perhaps unsurprisingly, the numerous ways to categorize coping have complicated the measurement and conceptualization of higher-order coping. Researchers also point to the great degree of overlap in coping functions and argue that conceptualizing coping as serving one goal (e.g., problem-focused versus emotion-focused) is problematic because a coping strategy is likely to serve many functions (Skinner & Zimmer-Gembeck, 2007). Adaptive and Maladaptive Coping Throughout existing literature, references are often made to categories of âadaptiveâ and âmaladaptiveâ coping responses. Although no definitive description of adaptive and maladaptive 7 coping is provided, studies often use factor analytic results to support the existence of this distinction (e.g., see Heffer & Willoughby, 2017). There are several problems with using the adaptive versus maladaptive distinction in coping. For example, researchers note that categorizing coping responses as simply positive or negative, or adaptive or maladaptive, may be problematic given that responses may be adaptive in certain contexts (e.g., distraction when facing an unsolvable problem), but maladaptive in other contexts (e.g., distraction when one needs to study for an exam; Heffer & Willoughby, 2017). In addition, there are mixed results in the literature regarding some coping styles and whether they are associated with greater or less distress. For example, some research finds that greater use of emotion-focused coping is associated with greater suicidality (Guerreiro et al., 2013). In contrast, other research finds greater use of emotion-focused coping to be associated with less suicidality (Marty et al., 2010). Yet another problem with the adaptive-maladaptive distinction is the difficulty in evaluating whether coping is adaptive or maladaptive. For example, a study using ecological momentary assessment found that certain coping responses, such as distraction (typically considered adaptive), predicted decreased future suicidal ideation, but mindfulness-based coping responses (typically considered adaptive) were unrelated to future suicidal ideation (Stanley et al., 2021). These results may lead one to conclude that distraction-based responses are âadaptiveâ, whereas mindfulness-based responses are not. However, when participants were asked to rate how effective they perceived the coping responses to be, they rated both distraction and mindfulness-based responses as equally effective. The authors of this study (Stanley et al., 2021) conclude that there is a disconnect between oneâs perception of coping effectiveness and actual effectiveness. However, it is important to consider additional explanations, including whether the specific timeframe during 8 which suicidal ideation was assessed properly captured subsequent changes in suicidal ideation. For example, certain coping responses, such as distraction, may be helpful in the short term; however, they may cause problems in the long term if one is not also addressing the source of their distress (e.g., interpersonal problems, work overload, etc.). Another consideration is whether no subsequent change in suicidal ideation should actually be considered a positive outcome. For example, the use of a coping response may simply prevent suicidal ideation from worsening, as it may have in the absence of any coping, and thus still be considered effective (Linehan, 1993). Concerning coping responses that are traditionally considered âmaladaptiveâ, research suggests that even these coping responses may carry some benefit, albeit typically only in the short term. For example, despite an overwhelming focus on the negative impacts of alcohol use, research also identifies potential benefits from alcohol use, including on oneâs mood and sociability (Peele & Brodsky, 2000). Another example comes from research on NSSI, a coping response often considered âmaladaptiveâ. Among various motivations reported for engaging in NSSI, one is that it serves an âanti-suicideâ function, in that self-harm helps individuals resist urges to act on suicidal ideation (Klonsky, 2007). However, over longer time scales, there is robust evidence that NSSI increases risk for suicide attempts (Hamza et al., 2012). It is clear from these examples that a simple identification of coping responses as âadaptiveâ or âmaladaptiveâ misses the nuance that is part of coping, and further research is required to better understand how coping responses may be both advantageous and/or harmful. Despite these complications in using âadaptiveâ and âmaladaptiveâ categories to conceptualize coping, these categories nevertheless remain commonly used in clinical settings (e.g., Linehan, 2015), research on coping in suicidal populations (Southward et al., 2023) and in 9 the SSC literature (Stanley et al., 2021). Thus, one of the ways in which this dissertation examines SSC is in accordance with these categories. However, given the additional ways in which this dissertation examines SSC, findings are likely to further our understanding of the helpfulness (and harmfulness) of coping. Coping Flexibility Another perspective on coping moves beyond focusing on specific coping responses as strictly adaptive or maladaptive and instead emphasizes flexibility in coping (Aldao et al., 2015; Bonanno & Burton, 2013). This focus argues that coping must be flexibly adapted to different stressors, and that the context of coping plays a key role. Although this view has become increasingly examined in research, it can be traced back to Lazarus and Folkmanâs Transactional Theory of Coping (Lazarus & Folkman, 1987). Their theory states that coping is an evolving process and differs in effectiveness according to the current context. As such, assessing the versatility in oneâs ability to use and switch between coping responses may be more important than examining which coping responses an individual is more likely to endorse using in general. More recently, Bonanno and Burton (2013) outline three key components to coping flexibility, including context sensitivity (e.g., the ability to perceive and understand contextual demands), repertoire (e.g., the variety or range of coping responses available to an individual), and responsiveness to feedback (e.g., the ability for an individual to incorporate feedback which may involve monitoring and adjusting coping responses as needed based on effectiveness). Building on this framework, Aldao and colleagues (2015) proposed additional key components to evaluating adaptiveness and flexibility of coping, including the extent to which coping results in enhanced likelihood of achieving goals that are meaningful to that person (e.g., experiencing 10 calmness, reducing outbursts of anger at work), and the synchronization between the variability in oneâs coping with variability in the environment. This perspective further adds to the concept of adaptivity in coping and how flexibility is related to it. In support of the importance of examining flexibility of coping, a meta-analytic review of 101 studies found a small to moderate positive effect between flexibility in coping and psychological adjustment (Cheng et al., 2014). These findings suggest that the ability to take a versatile approach to coping is associated with more positive outcomes. Another study assessed the overall number of different coping responses that participants reported using and found that the overall count of adaptive coping responses was associated with better outcomes (e.g., lower suicidal ideation, higher self-esteem; Heffer & Willoughby, 2017). However, this relationship was not observed when only the mean frequency with which participants used adaptive coping responses was assessed. Authors concluded from these results that assessing the number of different coping responses an individual engages in provides distinct information from simply assessing the frequency with which one copes (Heffer & Willoughby, 2017). Coping and Emotion Regulation Another point to consider when discussing the construct of coping is the distinction between coping and emotion regulation. In a meta-analysis of coping and emotion regulation, Compas et al. (2017) note that a central unifying feature of these constructs is their role as regulatory processes (Compas et al., 2017). As regulatory processes, coping and emotion regulation both involve efforts to regulate the initiation, duration, intensity, and content of thoughts, emotions, behaviors, or physiological reactions (Compas et al., 2001, 2017). Despite these similarities, a key difference is that coping is concerned with regulation in response to a 11 stressor (e.g., job loss, relationship conflict, a health condition, intrusive thoughts in OCD, suicidal ideation). In contrast, emotion regulation occurs in response to an emotion, which may or may not occur in the presence of a stressor (Compas et al., 2017). As such, coping may include non-emotional actions or responses taken to achieve non-emotional goals (Gross, 1998; Skinner & Zimmer-Gembeck, 2007). For example, a commonly recommended SSC response is taking steps to reduce oneâs access to lethal means (i.e., means safety; Anestis et al., 2017). Although strong emotions may accompany suicidal ideation (Mou et al., 2018), this coping response is aimed at altering oneâs external environment with the goal of keeping oneself safe, regardless of impact on emotions. In considering the role of emotions in coping with suicidal ideation, research using ecological momentary assessment of suicidal ideation and negative affect finds that individuals exhibit a range of intensity in negative affect that co-occurs with suicidal ideation (Mou et al., 2018). In other words, the emotional experience that accompanies suicidal ideation is not homogenous. Although emotion regulation is associated with suicidal ideation (Turton et al., 2021), it is but one part of understanding how individuals may manage, cope with, and respond to their suicidal ideation. Thus, to capture a broader and more comprehensive understanding of the management of suicidal ideation, this dissertation focuses on coping with suicidal ideation as opposed to the relationship between emotion regulation and suicidal ideation. Quality versus Quantity of Coping Responses Although most research on coping tends to focus on the quantity or frequency with which coping responses or styles are used, it is also important to consider the quality of the coping 12 skills used. In DBT, a treatment often used with suicidal clients, there is an emphasis on acquiring and learning about coping skills, practicing coping skills, and on the generalization of these skills across different contexts (Linehan, 1993; Neacsiu et al., 2010). In a randomized control trial of 8-weeks of CBT for substance use, the quality of coping responses, but not the quantity of coping responses, was found to increase in the CBT condition compared to the treatment as usual condition, with this difference persisting for 3 months following treatment (Kiluk et al., 2010). Authors also found that the quality of coping responses, but not the quantity of coping responses, was positively associated with abstinence from substances over the course of the study (Kiluk et al., 2010). These results highlight the importance of not just using coping responses, but using them skillfully. In considering how the quality of coping skills may impact SSC, it may be that certain coping skills require more or less skill to execute than others. For example, taking a hot or cold shower when distressed may be a more straightforward coping response requiring less skill to execute. On the other hand, using interpersonal skills to reach out to friends and family for help while in a state of high emotional arousal and distress may be a coping response that requires greater skill and practice to execute effectively (Linehan, 1993). Measurement of Coping Different measures of coping have been developed to capture conceptually different understandings of coping, for example, dispositional coping versus situational coping, or different categories of higher order coping. Meta-analysis of coping measures suggests that over 20 different scales are frequently used in the literature to assess coping, each varying in terms of 13 content, comprehensiveness, and psychometric properties (Kato, 2015). This study identified the Coping Orientations to Problems Experienced Scale (COPE), or the shortened version, the Brief COPE (Carver, 1997; Carver et al., 1989) as the most frequently used measure between the years 1998 and 2010 (Kato, 2015). These measures have been used in various populations and assess a broad range of coping responses that people usually use in response to a stressful or difficult situation. The COPE consists of 53 items that make up 14 different scales corresponding to different lower order coping responses. The Brief COPE was developed by selecting items with strong factor loadings, revising and shortening some existing items to improve item clarity, and adding an additional two items for a new scale to capture self-blame (Carver, 1997). The result is a 28-item measure with 14 scales of different lower order coping responses that have some degree of overlap with the original COPE measure: self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and self-blame. Although widely used, some researchers suggest that the COPE and Brief COPE have too many scales and poor within-scale reliability (Kato, 2015; Lyne & Roger, 2000). Further, the COPE and Brief COPE do not provide instructions for combining scales to assess higher-order coping styles, and no overall score of coping (Carver et al., 1989). Researchers are instead directed to assess the factor structure of the measure in their sample and use the higher-order factor structure that emerges (Carver et al., 1989). The consequence of this is a literature reporting on a variety of different higher-order styles of coping and their relation to outcomes of interest (e.g., Cramer et al., 2020; Gutiérrez et al., 2007; Lyne & Roger, 2000; Wang et al., 2018). In an effort to address this lack of consistency in how the Brief COPE is used, a recent systematic review was conducted to examine the factor structure of the Brief COPE (Solberg et 14 al., 2022). Authors found that a simple 2-factor structure was frequently used in the literature and may be an appropriate and parsimonious fit for the measure (Solberg et al., 2022). Summary: Conceptualizing and Measuring Coping Upon reviewing the literature on the conceptualization of coping, this dissertation defines SSC as follows. Drawing upon Lazarus and Folkmanâs original definition, coping is defined as both thoughts and actions taken in order to manage a specific stressor: suicidal ideation. For the reasons outlined above, coping with suicidal ideation in this dissertation will include thoughts and actions taken to manage suicidal thoughts that are engaged in deliberately with the purpose of coping, in addition to thoughts, and actions that are automatic responses to oneâs suicidal ideation. Following the theoretical and empirical research suggestions to examine the versatility or flexibility of coping, this dissertation examines a range of individual SSC responses discussed in the empirical literature, including the frequency with which they are used (i.e., frequency of individual SSC responses, frequency of adaptive and maladaptive SSC responses as a whole) and the variety of responses used (i.e., the overall number of different adaptive and maladaptive SSC responses used). The dissertation also considers oneâs knowledge and self-efficacy in coping with suicidal ideation as a dimension of SSC. General Coping and Suicide-Related Variables As illustrated above, there is an expansive and decades-long literature on general coping (i.e., coping with general distress). In contrast, coping with suicidal ideation specifically, which is the focus of this dissertation, is a relatively new topic of study (Stanley et al., 2017). However, there is a medium-sized literature in between these general and specific foci. A number of studies 15 have examined the relationship of general coping responses and styles to suicide-related variables and outcomes (e.g., suicidal ideation, suicide attempts). The following section reviews this broader area of research. Given the aforementioned discrepancies in how coping is defined and measured, summarizing research in this area proves challenging. In fact, some researchers have noted that the discrepancies in how coping is measured are so great that it prevents the possibility of meta-analytic procedures (Guerreiro et al., 2013). Despite these challenges, several patterns can be observed in terms of the relationship between certain coping approaches and suicide-related outcomes. Emotion-focused and Avoidance Coping Emotion-focused coping is a higher-order coping style that captures coping responses aimed at regulating oneâs affective response to a stressor (Lazarus & Folkman, 1984). Emotion-focused coping is found to be associated with poorer outcomes in research. For example, a systematic review of 18 studies found that the use of emotion-focused coping styles, particularly avoidant coping, demonstrated small to large positive associations with severity of suicide-related variables (Guerreiro et al., 2013). A similar pattern is observed in additional studies with effects ranging from small to large for the association between greater use of emotion-focused and avoidant coping and more severe suicide-related variables (e.g., Batchelor & Taylor, 2021; Benatov et al., 2020; Cramer et al., 2020; Gonzalez, 2019; Marusic & Goodwin, 2006; Pienaar et al., 2007). In contrast to this pattern, other research findings suggest that greater use of emotion-focused coping responses may be associated with decreased suicidality (Marty et al., 2010). One 16 explanation suggested for the discrepancy in these findings is that the direction of the effect is related to the types of emotion-focused responses assessed (Marty et al., 2010). For example, studies that tend to assess emotion-focused coping responses aimed at regulating affective responses by avoiding or blaming others (i.e., avoidance) are associated with increased suicide risk. On the other hand, emotion-focused coping responses, such as thinking about good memories, may be associated with decreased suicide risk (Marty et al., 2010). Problem-solving Coping Research on problem-solving yields a mixed pattern of results. The systematic review conducted by Guerreiro and colleagues (2013) and an additional systematic review of 22 studies that examine problem-solving coping specifically (Speckens & Hawton, 2005) both suggest an inconsistent relationship between problem-solving coping and suicide-related variables. For example, some research finds small and statistically insignificant associations between problem-solving coping and suicide-related variables (Andover et al., 2007; Cramer et al., 2020; Horwitz et al., 2011). In contrast to this, other researchers find small to medium sized effects to suggest that greater problem-solving coping responses are associated with less intense suicidal ideation (Batchelor & Taylor, 2021; Marty et al., 2010; Pienaar et al., 2007; Zortea et al., 2020). This mixed pattern of results may suggest that interventions that focus only on increasing adaptive coping responses (e.g., problem-focused coping) may be an insufficient approach. Given the more consistent relationship observed between maladaptive coping (e.g., avoidant coping) and suicide risk (Guerreiro et al., 2013), researchers suggest that in addition to increasing adaptive coping responses, interventions should focus on reducing maladaptive coping responses (Horwitz et al., 2011; Southward et al., 2023). 17 Longitudinal Studies The research reviewed thus far is largely drawn from cross-sectional studies. As such, based on these studies, it is impossible to ascertain the direction and temporal nature of the relationship between coping and suicide-related outcomes. Longitudinal work in this area is particularly important because of the likelihood of a bidirectional relationship between coping and psychopathology (Zimmer-Gembeck & Skinner, 2016). For example, although poorer coping may predict greater distress in the future, distress itself may also impair the development of or oneâs ability to engage in productive coping responses (Compas et al., 2017). One example of the potential nuance in the bidirectional relationship between coping and psychopathology comes from a one-year longitudinal examination of coping and psychopathology in a pre-adolescent sample (Richardson et al., 2021). This study found that greater use of avoidance coping responses predicted greater anxiety symptoms and eating pathology one year later. On the other hand, greater levels of depression predicted decreases in problem-solving coping responses one year later (Richardson et al., 2021). Although this study did not assess suicide-related outcomes specifically, it draws attention to the differential ways in which coping and psychopathology may be longitudinally related. In the few studies that examine the longitudinal relationship between coping and suicidal ideation, there is initial evidence to suggest a bidirectional relationship. Horwitz and colleagues (2018) conducted a longitudinal examination of coping styles and suicidal ideation and attempts in a sample of adolescents and young adults accessing the psychiatric emergency department. This study found that avoidance coping (assessed as disengagement and giving up on attempts to cope), predicted increased suicidal ideation four months in the future after controlling for baseline suicidal ideation. Another study conducted in a large sample of Canadian 18 undergraduates (n=1,132) found that using a greater number of different adaptive coping responses predicted decreased suicidal ideation one year later, after controlling for suicidal ideation at baseline (Heffer & Willoughby, 2017). Research from Stanley and colleagues (2021) provides evidence for the possibility that suicidal ideation predicts future coping. In their study, which used ecological momentary assessment over one week, they found that greater intensity of suicidal ideation reported at baseline was associated with fewer general coping responses used over the course of the following week (Stanley et al., 2021). Together, results suggest that there is a relationship between general coping and future suicidal ideation, and that suicidal ideation also predicts how an individual may cope in the future. Further research is required to continue to elucidate the possible bidirectional relationship between coping, especially SSC, and suicidal ideation. Summary: General Coping and Suicide-Related Variables Overall, it appears that an emotion-focused coping style, particularly the use of avoidant coping responses, is associated with more severe suicide-related outcomes. Although greater use of problem-solving coping responses is found to be associated with better outcomes, the evidence for this relationship appears to be more inconsistent. Finally, limited longitudinal work suggests that certain coping responses predict future suicidal ideation, and that the severity of oneâs suicidal ideation also predicts future coping. Suicide-Specific Coping (SSC) There is growing interest in the field of suicide research in examining how individuals cope with their suicidal ideation (Stanley et al., 2017). This growing interest is unsurprising 19 given the major emphasis placed on coping with suicidal thoughts in many clinical interventions over the past several decades. For example, coping with suicidal ideation is a major focus in a leading intervention for suicidal patients, the Safety Planning Intervention (SPI; Stanley & Brown, 2012). The SPI is a brief intervention designed primarily for use in Emergency Departments and involves creating a safety plan which consists of different coping responses an individual can use when experiencing a suicidal crisis. The safety plan created in the SPI is unique to the individual, with coping responses generated after analyzing the sequence of events leading up to a recent suicide attempt or suicide event (Stanley & Brown, 2012). Research examining the SPI finds that this intervention is protective against future suicide attempts (Nuij et al., 2021) and is associated with an increased likelihood of seeking mental health treatment compared to care as usual (Stanley et al., 2018). Another study conducted among adolescents following hospitalization also found that safety planning was protective against future suicidal ideation and resulted in enhanced coping (Czyz et al., 2021). In addition, a study assessing safety planning through a smartphone application found that over the course of the two months, participants demonstrated a reduction in suicidal ideation and an improvement in an individualâs knowledge of coping skills and self-efficacy in coping with suicidal ideation (Melvin et al., 2019). In addition to the SPI, Dialectical Behavior Therapy (DBT; Linehan, 1993) is an evidence-based intervention designed specifically for individuals who are suicidal. DBT emphasizes the learning and practice of skills to cope with distress, including suicidal ideation (1993). A recent meta-analysis of 18 controlled trials of DBT found this intervention to be effective at reducing suicidal behaviour, including suicide attempts. However, there was not a robust effect of DBT for reducing suicidal ideation (DeCou et al., 2019). Authors suggest that the 20 lack of an effect for suicidal ideation may be due to limitations such as a small number of studies and samples sizes which assessed suicidal ideation. However, another possible conclusion is that these findings reflect the prioritization of suicidal behaviours (e.g., suicide preparations, suicide attempts, and NSSI) over suicidal thoughts in DBT. Related to this, Stanley and colleagues (2017) note that suicide-specific interventions, such as DBT, often target increasing SSC rather than decreasing suicidal ideation. In other words, coping with suicidal ideation may result in a decreased likelihood of attempting suicide, though not decrease the actual intensity of oneâs suicidal ideation. Given the extent to which coping with suicidal ideation is a focus in clinical work (as reviewed above), it is perhaps surprising that research has only recently begun to focus on better understanding how individuals cope with suicidal ideation. Further research is needed to add to this growing literature and improve understanding of what effect SSC has on suicide risk. Knowledge and Confidence in SSC Stanley and colleagues were the first to suggest that the construct of âsuicide-related copingâ represents a unique form of coping that specifically concerns how individuals cope with and manage suicidal ideation. They define suicide-related coping as âknowledge of and perceived self-efficacy in the use of internal coping strategies and external resources to manage suicidal thoughts with the goal of decreasing imminent risk and averting suicidal crisesâ and developed the Suicide-Related Coping Scale (SRCS) to measure this construct (Stanley et al., 2017). This 17-item self-report measure assesses suicide-related coping as defined above and is composed of two factors: internal coping (awareness and use of self-guided coping responses) and external coping (knowledge of emergency and crisis services, willingness to seek support 21 from others). The SRCS was administered to a sample of 329 adults at risk for suicide who had presented to the Emergency Department or were psychiatrically hospitalized. This measure was found to demonstrate small to medium negative associations with three separate measures of suicidal ideation severity, in addition to demonstrating a small negative association with lifetime history of suicide attempts (Stanley et al., 2017). The SRCS has since been examined in a sample of 64 Veterans who were assessed to be at high risk for suicide. In this sample, the SRCS predicted subsequent suicide attempts over the follow-up time of 90 days even after controlling for suicide risk factors including lifetime history of suicide attempts, severity of suicidal ideation at baseline, and presence of a mood disorder (Interian et al., 2021). Notably, this study also found that the SRCS continued to predict the occurrence of future suicide attempts after adding distress tolerance to the model. These findings suggest that the SRCS may add unique information to predicting suicide attempts over and above established suicide risk factors, including suicidal ideation severity, suicide attempt history, mood disorder diagnosis, and oneâs ability to cope with or tolerate distress in general (Interian et al., 2021). The factor structure of the SRCS has also been examined in two large online Australian samples (Rainbow et al., 2023). In both samples, a three-factor solution was found: internal coping, external coping, and perceived control. Similar to previous work, the SRCS exhibited a strong negative correlation with recent suicidal ideation and future suicide intent, and also demonstrated a moderate positive relationship with distress tolerance. Interestingly, in this study, the SRCS was strongly correlated with help-seeking intent, but minimally associated with actual help-seeking behaviors (Rainbow et al., 2023). Authors suggest that this finding might be similar to a phenomena commonly seen in lifestyle medicine known as the âintention-behavior gapâ 22 (Faries, 2016), where a personâs intention is often a poor predictor of their health behavior. This would suggest that in addition to inquiring about oneâs knowledge and confidence in coping with suicidal ideation, it is important to understand the actual use of SSC responses. Most recently, a study examined SRCS at four time points across one year and found SRCS to covary with levels of depression, hopelessness, social connection, and reasons for living (Glatt et al., 2025). Although this study did not examine the predictive relationship between the SRCS and these variables over time, it adds to this growing literature and suggests that knowledge and confidence in SSC fluctuates with suicide risk and protective variables over periods of several months. Finally, one additional measure has been developed to capture confidence in SSC. Developed by Czyz and colleagues (2016), the Efficacy to Cope with Suicidal Thoughts and Urges Scale examines oneâs confidence in using 10 different coping responses when suicidal. This measure was administered in a sample of adolescents and young adults recruited from a psychiatric emergency department. Results found that confidence ratings for each SSC response were generally low to moderate and that confidence in SSC exhibited small to large negative associations with suicidal ideation severity (Czyz et al., 2016). This study, in addition to research using the SRCS, emphasizes the importance of considering oneâs confidence in SSC. Individual SSC Responses Although the development of the SRCS and Efficacy to Cope with Suicidal Thoughts and Urges measures has advanced understanding of SSC and suicide risk, these measures fail to provide information regarding the specific responses an individual uses to cope with suicidal ideation. Relatively less research has been conducted to examine the responses individuals may 23 use to cope with their suicidal ideation. One study conducted in a sample of 187 American adults asked participants to provide a list of up to five responses they have used to cope with suicidal thoughts (Alexander et al., 2009). The most commonly reported coping responses were: turning to spirituality or religious practices, speaking with someone, and positive thinking, whereas uncommon responses were resting and seeking emotional outlets (Alexander et al., 2009). A limitation of this study was that participants were only asked to report on coping responses used in moments of âsuicidal crisesâ, and thus these results may not reflect the most commonly used responses for managing more mild to moderate levels of ideation that individuals are more likely to experience day to day (Kleiman et al., 2018). Although oneâs ability to cope with severe suicidal thoughts is of importance, interventions for suicidal individuals often emphasize the importance of using âwarning signsâ to identify suicidal ideation at more mild to moderate levels to cope with before that suicidal ideation escalates to a more severe intensity (Stanley & Brown, 2012). Another limitation of this study is that the authors did not assess the impact of coping responses. As such, it is unclear how helpful or effective these coping responses may be for managing suicidal ideation. A second study, which addresses some limitations noted above, surveyed an online anonymous sample of 588 individuals with a lifetime history of suicidal ideation about the use and perceived helpfulness of 18 different SSC responses (Simon et al., 2016). This study found that doing things to stay busy, watching TV/entertainment, doing things with other people, using positive self-talk, and talking with a therapist were the SSC responses endorsed by the largest proportion of participants, whereas seeking online peer support and calling a crisis centre were uncommon (Simon et al., 2016). In addition to asking whether participants had ever used each of the 18 SSC responses, this study also asked participants to report on how helpful coping 24 responses were perceived to be. Results from this study suggest that there are a broad range of different coping responses individuals may use to cope with suicidal ideation. Findings also provide evidence that for each of the SSC responses assessed, at least some participants rated a response as helpful, and at least some rated it as harmful. In other words, no single response was rated as unanimously helpful or harmful, reflecting individual differences in SSC (Simon et al., 2016). Also adding to the literature on the specific responses individuals use to cope with suicidal ideation is a study that examined different categories of internal coping responses (i.e., SSC responses an individual can do without the assistance of another person) that were either user-generated or suggested by a safety planning app (Daglas et al., 2024). This study identified 11 categories of SSC responses from 680 participants who had used this safety planning app, with the most frequent entries for categories involving Media consumption (i.e., watch tv, listen to music, read), Relaxation (i.e., sleep, meditation), Exercise (i.e., go to the gym, do yoga), and Creativity (i.e., hobbies such as play music, paint). Although this study did not examine the actual use of these responses, it does speak to the wide variety of SSC responses individuals may engage in. Together, these studies provide initial information about the potentially broad range of responses people may use to cope with suicidal ideation. In addition, results from Simon and colleagues (2016) are the first to explore the potential helpfulness or harmfulness of specific coping responses. However, certain limitations persist. First, no study asked about the frequency with which certain responses were used, with the Simon and colleaguesâ (2016) study relying on a dichotomous yes/no answer. As a result, it is unclear which SSC responses are most and least commonly used relative to others. In addition, although Simon and colleaguesâ (2016) study 25 asked about the helpfulness and harmfulness of coping responses, it is unclear how these perceived effects were operationalized. It is possible that âhelpfulâ coping could lead to different outcomes, including less desire to die, less suicide intent, or just feeling better in general. Further research is needed to clarify what it means for coping responses to be helpful or harmful in coping with suicidal ideation. Most recently, Stanleyâs research team used ecological momentary assessment methodology to further advance understanding of coping and subsequent suicidal ideation that day (Stanley et al., 2021). In this study, 50 participants with a diagnosis of BPD who also reported current suicidal ideation completed one week of ecological momentary assessments. Participants were prompted to complete six assessments per day which asked about current suicidal ideation intensity and if they had engaged in seven different general coping responses since the last survey: keeping busy, socializing, positive thinking, doing something good for self, calming self, finding perspective, and sitting with feelings until they passed. Overall, results from this study suggest that different types of coping (e.g., distraction versus mindfulness-oriented responses) demonstrate distinct relationships with subsequent suicidal ideation (Stanley et al., 2021). Specifically, distraction responses predicted decreased suicidal ideation, whereas mindfulness-oriented responses were not associated with future suicidal ideation (Stanley et al., 2021). Despite the actual differences observed in subsequent suicidal ideation following distraction versus mindfulness-oriented coping responses, all coping responses were rated as effective by participants (Stanley et al., 2021). These results raise several interesting possibilities, including the possibility that oneâs own perception of coping response effectiveness does not always align with subsequent decreases in suicidal ideation. However, it is interesting to note 26 that distraction responses appear to have been rated as more effective compared to how effective mindfulness-oriented responses were rated. Thus, perhaps perceived effectiveness aligns to some extent with later reported reductions in suicidal ideation. Another possibility in interpreting these findings concerns the length of time between the use of the coping response and suicidal ideation assessment. It is possible that mindfulness-oriented responses resulted in altered suicidal ideation, however, that the timeframe with which suicidal ideation was next assessed did not capture this. Limitations of Existing Research Despite these advancements in research on the measurement of SSC, knowledge of SSC responses, and the relationship between SSC and suicidal ideation and suicide outcomes, important limitations in this literature remain. These limitations have been touched on in the reviewed literature above, and overall, represent two areas for which the research on SSC is lacking: basic knowledge regarding frequency and helpfulness of SSC responses, and the longitudinal relationship between SSC and suicidal ideation. These limitations guided the development of this dissertation. First, the current literature is limited in knowledge regarding the specific coping responses used to cope with suicidal ideation and their perceived effectiveness. Although three studies (Alexander et al., 2009; Daglas et al., 2024; Simon et al., 2016) provide information that speaks to specific responses used for coping with suicidal ideation, no research thus far provides any information regarding the frequency with which these SSC responses are actually used. Without information about the frequency with which coping responses are used, it is impossible 27 to ascertain basic information regarding which coping responses are used most often to cope with and respond to suicidal ideation. Related to the limitation noted above, there is a significant gap in knowledge regarding the effects of different SSC responses on suicidal ideation. Although one study assessed the perceived impact of SSC (Simon et al., 2016), the study did not ask about the perceived impact on suicidal ideation. Instead, participants were asked to rate each SSC response as generally harmful or helpful. As such, results do not provide information on how SSC responses may be perceived to more immediately impact suicidal ideation. Building on these findings, one study used ecological momentary assessment to assess general coping responses and subsequent suicidal ideation and found results to suggest that certain coping responses (i.e., distraction) may be more effective than others (i.e.., mindfulness-oriented) in reducing subsequent future suicidal ideation (Stanley et al., 2021). However, this study asked about coping responses in general and did not assess whether responses were used specifically to cope with suicidal ideation. Thus, we still know very little about the effectiveness and harmfulness of the different coping responses individuals use to cope with suicidal ideation. Determining the effectiveness of coping is further complicated by emerging information regarding the construct of suicidal ideation. For example, existing research on SSC has examined suicidal ideation as a unidimensional construct; however, suicidal ideation has been found to consist of distinctive components, including desire to die and preparations and plans for suicide (Beck et al., 1979, 1997; Dhingra et al., 2019). More recent work suggests that there are facets of suicidal ideation, including wish to live and wish to die, that represent separate yet related components of suicidal ideation (Oakey-Frost et al., 2023; Rudd & Bryan, 2022). However, no research to date has examined the extent to which different coping responses affect these facets 28 of suicidal ideation, including wish to live, wish to die, or oneâs intent to act on their suicidal thoughts. A second major limitation of the current literature is that much of the research conducted thus far has been cross-sectional in nature. Longitudinal research is necessary in order to understand the direction of the relationship between SSC and suicidal ideation. For example, it is possible that SSC leads to changes in subsequent suicidal ideation, that intensity of suicidal ideation impacts subsequent SSC, or that the relationship between these variables is bidirectional. However, no research to date has examined this relationship. Only one longitudinal study on SSC has been conducted thus far, and examined whether SSC predicted the occurrence of a future suicide-related events (e.g., suicide attempt, hospitalization for ideation) over a 90 day time period (Interian et al., 2021). Future work is needed to better understand the impact of SSC at different, including shorter, timeframes. Another limitation of longitudinal research thus far is that it has focused solely on examining adaptive coping responses (Stanley et al., 2021). There is perhaps a good reason for this, as these adaptive coping responses are the responses clinicians may be most concerned with teaching and reinforcing. However, there is a danger in only assessing adaptive coping responses given additional research which suggests coping responses traditionally considered in clinical settings to be maladaptive, such as drug and alcohol use (Simon et al., 2016), and NSSI (Klonsky, 2007), are frequently reported by individuals as ways to cope with suicidal ideation. In addition, the previous research reviewed on coping highlights the importance of targeting maladaptive coping responses in addition to enhancing adaptive coping responses (Horwitz et al., 2011; Southward et al., 2023). Given the prevalence of maladaptive coping responses in the 29 context of suicidal ideation, it is important to also examine the impact that maladaptive SSC responses have on future suicidal ideation. Finally, there is limited understanding as to why coping with suicidal ideation may be helpful. For example, although the SRCS (Stanley et al., 2017) provides evidence that greater knowledge and self-efficacy in coping is associated with less suicidal ideation, it is unclear why exactly this association exists. One possibility is that those who have greater knowledge and self-efficacy in coping with suicidal thoughts also use coping responses more frequently. However, no study has examined the relationship between the SRCS and suicidal ideation while also accounting for the actual use of SSC responses. In addition, though past research states that SSC is a unique construct compared to coping in general (Stanley et al., 2017), only one study has examined whether SSC maintains a unique relationship with suicide risk when controlling for general distress tolerance abilities (Interian et al., 2021). Further research is needed to determine whether SSC is uniquely associated with suicide-related variables or whether this association is explained by better coping abilities in general. A final consideration for why SSC may reduce suicidal ideation lies in theoretical explanations for suicidal ideation. A prominent theory of suicide, the Three Step Theory (3ST; Klonsky et al., 2015, 2021), emphasizes the role of pain and connectedness in explaining the intensity of suicidal ideation. In accordance with 3ST predictions, it is possible that engaging in coping responses to manage suicidal ideation decreases pain in oneâs life (e.g., engaging in exercise or other behaviour activation strategies decreasing a depressed mood), or increases how connected one feels to others (e.g., reaching out to friends and family). Thus the intensity of suicidal ideation may be reduced as a result of the impact coping has on pain or connectedness. 30 Further research is needed to better understand the ways in which SSC is linked with suicidal ideation in the context of these theory-informed variables. Current Dissertation Because SSC is just emerging as a focus in the empirical literature, many important and basic questions remain unanswered. The overarching aim of this dissertation was thus to begin addressing some of these fundamental questions about SSC. To do so, this dissertation took a largely exploratory and descriptive approach to examining SSC and the relationship between SSC and suicidal ideation across two studies. Specifically, Study 1 aimed to address a central knowledge gap in the SSC literature regarding the frequency of SSC and the perceived impact of different SSC responses on suicidal ideation. Study 1 also examined the cross-sectional relationship between SSC and suicidal ideation and attempts. Study 2 focused on further understanding the relationship between SSC and suicidal ideation by examining both cross-sectional and longitudinal relationships between these variables. For its longitudinal timeframe, Study 2 examined the relationship between SSC and suicidal ideation from one week to the next. There are many potential timeframes of interest for examining the relationship between SSC and suicidal ideation, such as the impact of SSC on ideation in the immediate seconds or minutes that follow coping, subsequent days or weeks, or even longer. A one week timeframe was chosen for this study for several reasons. First, although longer timeframes (such as over 90 days, as examined previously; Interian et al., 2021) are useful for understanding the extent to which patterns of SSC predict suicide risk over time, this time period does not speak to the more direct impacts of SSC on subsequent ideation. A shorter timeframe of one week to the next is more likely to capture a more direct 31 relationship between SSC and ideation. Past research using this specific timeframe has found that past week emotion regulation strategies (i.e., suppression and rumination; Thompson et al., 2025) and past week behavioral dysregulation (Selby et al., 2013) predict next week ideation. Thus, it is reasonable to expect that a one-week timeframe would provide insight into the impacts of past week SSC on next week ideation. Second, while an even shorter timeframe (e.g., minutes, hours) could be argued to represent the clearest picture of SSC and subsequent ideation, research has shown that strategies that appear helpful over these very acute timeframes are not always helpful or adaptive. For example, clinically relevant behaviors â such as, NSSI, substance use, eating disordered behaviors â are found to be associated with temporary reductions in distress and even reductions in suicidal ideation (e.g., Herzog et al., 2022; Treloar et al., 2015; Wonderlich et al., 2022), but associated with increased distress over longer timeframes (e.g., Hamza et al., 2012; Puccio et al., 2017; Zhang & Wu, 2014). A timeframe of one week was thus chosen for Study 2 to capture a long enough time period such that any apparent improvements in ideation linked to past SSC would be more likely to represent adaptive coping, rather than temporary relief via maladaptive behavior. Finally, one week is a common timeframe in which clinicians may hope to see clinical change when working with clients in outpatient settings. For example, a clinician treating a client with suicide risk at a given session may be especially interested in how different SSC mechanisms discussed in that session may impact suicidal ideation over the subsequent week and until the next session. As such, this one week timeframe is likely to provide relevant information to clinicians who work with suicidal clients within this time period in their clinical practice (Schleider et al., 2021). 32 Study 1 Research Questions Study 1 used a semi-structured interview and self-report methodology to examine how individuals cope with their suicidal ideation. Participants were undergraduates from the University of British Columbia, an important population in which to examine suicidal ideation and coping given the prevalence of suicidal ideation among undergraduates (Mortier et al., 2018). In fact, a recent study of students at the University of British Columbia between March 2020 â May 2021 found that approximately one-fifth of undergraduates among over 2,000 assessed had experienced suicidal ideation in the past month (Jones et al., 2023). As Study 1 of this dissertation occurred during an overlapping time period (2018 â 2022), it may be especially valuable to better understand SSC within this population. Four dimensions of SSC were explored in Study 1: (a) Frequency, which captured how often SSC responses were used (including frequency of individual responses and frequency of adaptive and maladaptive responses as a whole); (b) Variety, which captured the overall number of different adaptive and maladaptive SSC responses used; (c) Perceived impact of SSC responses on suicidal ideation; and (d) Knowledge/Confidence, which captured an individualâs general knowledge and self-efficacy in SSC. Study 1 had three research questions: (1) Which SSC responses are used most and least frequently? (2) What is the perceived impact of SSC responses on suicidal ideation? (3) What is the relationship between SSC and suicidal ideation and attempts? These research questions are described in detail below. Research Question 1 (Study 1): Which SSC responses are used most and least frequently? This first research question focused on the Frequency dimension of SSC. Participants were asked about the frequency with which they had used a range of different SSC responses, including adaptive and maladaptive responses. In order to assess these responses, a 33 semi-structured interview was developed, as no tools or measures currently exist in the literature which assess individual SSC responses. Given the limitations of research in this area previously described, this research question was exploratory in nature. Research Question 2 (Study 1): What is the perceived impact of SSC responses on suicidal ideation? This second research question focused on the Perceived impact dimension of SSC. Research suggests that suicidal ideation is a multi-faceted construct, including subcomponents such as desire to die, wish to live, and intent to act on suicidal thoughts (Beck et al., 1979, 1997; Dhingra et al., 2018; Oakey-Frost et al., 2023; Rudd & Bryan, 2022). Some research suggests that coping skills may differentially affect these subcomponents of suicidal ideation. For example, some coping skills may help an individual manage their urges and intent to act on suicidal thoughts, but not necessarily decrease suicidal ideation intensity (DeCou et al., 2019; Stanley et al., 2017). As such, participants were asked about the extent to which they perceived each SSC response to impact their desire to die, desire to live, and suicide intent. Given the limitations of prior research, this research question was exploratory in nature. Research Question 3 (Study 1): What is the relationship between SSC and suicidal ideation and attempts? This third research question examined the extent to which SSC was associated with suicidal ideation and suicide attempts. Analyses examined three dimensions of SSC, including Frequency (i.e., frequency of individual SSC responses, frequency of adaptive and maladaptive SSC responses as a whole), Variety (i.e., the overall number of different adaptive SSC responses and different maladaptive SSC responses used), and Knowledge/Confidence, and the degree to which these dimensions were correlated with current suicidal ideation, worst-point ideation, and lifetime history of suicide attempts. Past research has consistently found negative associations between Knowledge/Confidence (measured using the 34 SRCS, Stanley et al., 2017) and suicidal ideation and lifetime suicide attempt history (Interian et al., 2021; Rainbow et al., 2023; Stanley et al., 2017). Thus, I hypothesized that adaptive SSC dimensions (i.e., Frequency, Variety, and Knowledge/Confidence) would be negatively associated with suicidal ideation and suicide attempts, and that maladaptive SSC dimensions (i.e., Frequency and Variety) would be positively associated with suicidal ideation and suicide attempts. Study 2 Research Questions Study 2 employed a two-wave longitudinal design to examine the relationship between adaptive and maladaptive SSC and suicidal ideation in an online sample of suicidal adults. As noted earlier, Study 2 chose to examine SSC and suicidal ideation over a one-week time period for several reasons. First, a period of one week is likely to more directly and precisely capture the longitudinal relationship between these variables compared to longer-term designs (i.e., periods of months). Second, research suggests that some coping strategies may have more temporary effects that do not align with longer-term effects. As such, Study 2 sought to understand the adaptive (or maladaptive) nature of SSC over a slightly longer time scale of one week. Finally, this weekly timeframe may also be of particular clinical relevance given the ubiquity of a one week timeframe in outpatient adult psychotherapy treatment sessions (Chu et al., 2015; Schleider et al., 2021). In Study 2, three dimensions of SSC were assessed: (a) Frequency, which captured how often SSC responses were used (including frequency of individual responses and frequency of adaptive and maladaptive responses as a whole); (b) Variety, which captured the overall number of different adaptive and maladaptive coping responses used; and (c) Knowledge/Confidence, 35 which captured an individualâs general knowledge and self-efficacy regarding SSC. Study 2 had three research questions: (1) What is the relationship between SSC and suicidal ideation? (2) Are different dimensions of SSC uniquely related to suicidal ideation beyond their association with general coping? (3) Is the relationship between SSC and suicidal ideation explained by variables emphasized in suicide theory? Research Question 1 (Study 2): What is the relationship between SSC and suicidal ideation? The first research question examined the cross-sectional and longitudinal relationships between SSC and suicidal ideation. Specifically, this question examined whether SSC and suicidal ideation were concurrently associated with each other, the extent to which past week SSC predicted next week suicidal ideation, and the extent to which past week suicidal ideation predicted next week SSC. Analyses examined three dimensions of SSC (Frequency, Variety, and Knowledge/Confidence). Previous cross-sectional research finds that Knowledge/Confidence in SSC is negatively associated with past week suicidal ideation (Interian et al., 2021). Therefore, I hypothesized that past week adaptive SSC (Frequency, Variety, and Knowledge/Confidence dimensions) would be negatively associated with past week suicidal ideation, and that past week maladaptive SSC (Frequency and Variety dimensions) would be positively associated with past week suicidal ideation. Previous longitudinal research finds that general coping responses predict reductions in suicidal ideation later that day (Stanley et al., 2021), that general maladaptive coping predicts greater suicidal ideation 4 months in the future (Horwitz et al., 2018), and that more adaptive general coping predicts decreased suicidal ideation one year in the future (Heffer & Willoughby, 2017). Regarding the possibility of a bidirectional relationship, research also suggests that higher 36 levels of suicidal ideation predicts less frequent use of general coping responses (Stanley et al., 2021), and that higher levels of suicidal ideation are correlated with greater endorsement of barriers to seeking help (Hom et al., 2015). However, no research to date has examined the longitudinal relationship between SSC and suicidal ideation. Thus, longitudinal analyses were exploratory in nature. Research Question 2 (Study 2): Is SSC uniquely related to suicidal ideation after accounting for coping-related covariates? This next research question investigated whether the relationship between SSC dimensions and suicidal ideation remained after controlling for coping-related covariates. First, SSC dimensions themselves were considered as covariates. Dimensions that predicted suicidal ideation in original analyses (i.e., research question 1) were entered into the same model predicting suicidal ideation to determine whether there were unique relationships between each dimension and suicidal ideation. For example, if both Adaptive Frequency and Maladaptive Frequency predicted suicidal ideation, both of these SSC dimensions would be included in the same model to examine the unique prediction of suicidal ideation. No research to date has examined whether distinct dimensions of SSC are uniquely related to suicidal ideation. Thus, these analyses were exploratory. Second, this relationship was examined when controlling for general coping covariates. SSC dimensions that predicted suicidal ideation in original analyses were entered in the same model as covariates, including general coping, distress tolerance, and emotion regulation. Although previous research finds a positive association between Knowledge/Confidence and higher general distress tolerance abilities (Interian et al., 2021; Rainbow et al., 2023), and that Knowledge/Confidence predicts a future suicidal event (i.e., suicidal behavior or hospitalization 37 for suicidal ideation) over and above general abilities to tolerate distress (Interian et al., 2021), no research has examined whether SSC maintains a relationship with suicidal ideation after controlling for distress tolerance (or additional coping-related covariates). As such, these analyses were exploratory. Research Question 3 (Study 2): Is SSC uniquely related to suicidal ideation after accounting for suicide theory-informed covariates? Research question three further examined the relationship between SSC dimensions and suicidal ideation, this time after controlling for covariates emphasized in suicide theory. I was specifically interested in variables theorized to play a role in suicidal ideation intensity (as opposed to the dichotomous presence versus absence of ideation), given that ideation is a key variable in analyses. The 3ST states that the intensity of suicidal ideation escalates when oneâs experience of pain overwhelms or exceeds their connectedness in life (Klonsky et al., 2021). As such, pain, connectedness, and the relative experience of oneâs pain versus connectedness were included as covariates in analyses for research question three. SSC dimensions that predicted suicidal ideation in original analyses were examined after including pain, connectedness, and the relative experience of pain versus connectedness as covariates. Given that all key variables in Study 2 (i.e., SSC, suicidal ideation, covariates) were assessed in terms of their aggregate experience over the past week, and that 3ST hypotheses describe the conditions that cause suicidal ideation to occur at a given moment in time, this study was not suitable for testing specific 3ST hypotheses with cross-sectional analyses (see Klonsky et al., 2021 for an elaboration on timeframes). In short, the 3ST is explicit in stating that suicidal ideation is predicted by current experiences of pain and connectedness, and that these can change within short-time frames such as hours or minutes (Klonsky et al., 2021). As such, there 38 were also no hypotheses for longitudinal analyses exploring the extent to which pain, connectedness, and the relative experience of pain versus connectedness may explain the relationship between past week SSC and next week suicidal ideation. 39 Study 1 Study 1 Methods Participants and Procedure Study 1 used a cross-sectional design and included 102 young adults with a lifetime history of suicidal ideation who were undergraduate students participating in the Department of Psychology Human Subject Pool (HSP) at the University of British Columbia (UBC). Potential participants for this study completed an online pre-screening questionnaire that included one question about lifetime history of suicidal ideation from the Youth and Risk Behavior Surveillance System questionnaire, âHave you ever seriously thought about killing yourself?â (Center for Disease Control and Prevention (CDC), 2024; Kolbe et al., 1993; May & Klonsky, 2011) embedded among other questions which asked about demographics and psychopathology. Participants who endorsed a lifetime history of suicidal ideation in the pre-screening questionnaire were presented with the option to sign up for this study among a list of all possible studies they could participate in. All participants were current undergraduate students attending UBC in the years 2018-2022. Participants completed the study in-person until March 2020 (n=64), and subsequently completed the study online using Zoom video conferencing platform due to COVID-19 restrictions on in-person data collection (n=36). A sensitivity analysis was included in the data analytic plan in order to examine potential differences across in-person versus online subsamples. Due to the sensitive nature of some questions asked in the study, only participants aged 19 and older were eligible to participate. In order to provide appropriate crisis and resource information for all participants, only participants currently residing in BC, Canada, and thus 40 eligible for local crisis and counselling resources, were eligible to participate in the online version of this study. At the beginning of the study, participants were greeted and consent procedures took place. Upon providing informed consent, the study began with a semi-structured interview, followed by a brief online survey of self-report measures, and finished with debriefing and provision of resources. All study procedures took place within one hour. For participants who reported current suicidal ideation, plans, and at least some intent to act on suicidal thoughts, a suicide risk protocol was followed that included a more detailed suicide risk assessment, safety planning, and connection to additional resources as necessary. This study (including the online amendments) received ethics approval through UBC. Demographic characteristics of the sample are reported below in Table 1. In summary, the mean age of participants was 21.58 (range = 19 â 46; median = 20), majority of participants identified their gender as woman (79%), over half reported a straight sexual orientation (68%), and regarding ethnicity and race, just under half reported being of East Asian descent (42%) and approximately a quarter reported being White/European (24%). 41 Table 1 Study 1 demographic characteristics Mean (SD) Range Age 21.58 (4.28) 19 â 46 n % Gender Woman 80 79% Man 18 18% Fluid, Nonbinary 3 3% English is Primary Language Yes 70 69% No 31 31% Racial and Ethnic Background Black 4 4% East Asian Descent 43 42% Indian-South Asian Descent 13 13% Indigenous 2 2% Latin American-Hispanic Descent 1 1% Middle Eastern Descent 1 1% Mixed race/ethnicity 7 7% Southeast Asian 6 6% White/European Descent 24 24% Sexual Orientation Straight (Heterosexual) 69 68% Bisexual 18 18% Gay 3 3% Questioning 1 1% Other 10 10% Working Yes 44 44% No 57 56% Hours Working per Week 1 â 9 hours 14 32% 10 â 19 hours 21 48% 20 â 29 hours 7 16% 30 â 39 hours 0 0% > 40 hours 2 4% Yearly household income (before tax) < $5,000 2 2% $5,000 - $9,999 6 6% $10,000 - $19,999 7 7% $20,000 - $29,999 6 6% $30,000 - $39,999 5 5% $40,000 - $49,999 6 6% $50,000 - $59,999 7 7% $60,000 - $74,999 10 10% $75,000 - $99,999 12 12% > $100,000 30 30% Prefer not to answer 10 10% Note. Sample size for demographic information is n=101 due to missing interview data (when demographics were assessed) for one participant; see results section for full details of missing data. 42 Measures All Study 1 measures are described below. Measures administered during the semi-structured interview portion of the study are listed first, followed by measures administered during the self-report survey portion of the study. Interview Measures. Coping with Suicidal Ideation Interview. A semi-structured clinical interview about coping with suicidal thoughts was developed by the author and Dr. E. David Klonsky based on a similar interview about coping with urges for NSSI (see Klonsky & Glenn, 2008). This interview was used to assess three dimensions of SSC: Frequency (i.e., frequency of individual SSC responses, and frequency of adaptive and maladaptive SSC responses as a whole), Variety (i.e., the overall number of different adaptive and maladaptive SSC responses used), and Perceived impact on suicidal ideation. The way in which this interview was used to assess these dimensions of SSC is detailed below. An initial version of the interview was piloted on six undergraduate research assistants for the current study, and revisions were made based on feedback and in consultation with Dr. Klonsky. The interview comprised a list of 36 adaptive and maladaptive SSC items that individuals may use to cope with and respond to suicidal ideation (please see Appendix A for the full interview). SSC items included in the measure were derived based on content a) found on suicide prevention websites or on social media platforms like Facebook or Instagram (e.g., calling a crisis line, talking to a friend, thinking about reasons for living; Canadian Association for Suicide Prevention, 2022), b) reported in the scientific literature on individuals at risk for suicide (e.g., using substances, engaging in NSSI without suicidal intent, reducing access to lethal means; Anestis et al., 2017; Gonzalez, 2019; Klonsky, 2007), and c) included in empirically supported treatments for suicide risk such as Dialectical Behavior 43 Therapy (DBT; e.g., mindfulness, distraction, taking a cold shower, engaging in physical activity; Linehan, 1993; 2015). The interview also included one open-ended question about additional coping responses a participant may have used that was not included in the list of 36 items. Instructions were first provided to participants about the structure and response options used for the interview. In these instructions, participants were told that they would be asked to rate the Frequency with which they use each coping response on a 5-point Likert scale (1 = âNeverâ, 2 = âRarelyâ, 3 = âSometimesâ, 4 = âUsuallyâ, 5 = âAlwaysâ). Participants were asked to rate each coping item with reference to times they were suicidal (as opposed to times where they were feeling down, anxious, or distressed in general), including both more recent and past history of suicidal thoughts. Perceived impact of the response was assessed for each item if participants reported using the item at least once (i.e., rated as 2 or higher). Perceived impact was assessed with three follow-up questions about the degree to which the participant perceived the coping item to impact: desire to die, desire to live, and suicide intent. Each of these three questions were answered using the following 5-point Likert scale: 1 = âincreased a lotâ, 2 = âincreased somewhatâ, 3 = âstayed about the sameâ, 4 = âdecreased somewhatâ, 5 = âdecreased a lotâ. Before beginning the interview, an explanation was provided to participants to help differentiate the facets of suicidal ideation they were asked about (i.e., desire to die, desire to live, and suicide intent), and any questions or concerns from participants answered. Following the administration of all the Frequency and Perceived impact of SSC items, participants were asked several additional questions about SSC that were not part of this studyâs main research questions. This included two open-ended questions about reasons for living, a 44 question about the percent of time they engaged in coping responses when feeling suicidal versus did not engage in coping responses, and a question about what was different between the times they coped versus did not cope with their suicidal thoughts. In addition, the 36 participants who completed the study following the start of the COVID-19 pandemic were asked questions about the potential impact of the pandemic on SSC. Twenty-three participants reported an overlap between when they were suicidal and the pandemic (remaining participants reported no suicidal thoughts since the pandemic had begun). These 23 participants were asked an open-ended question about the extent to which they believed that the pandemic impacted how they coped with suicidal ideation: 13 participants reported having greater difficulty coping with suicidal thoughts due to impacts of the pandemic (e.g., âit was tough to get connection with othersâ), four participants reported a positive impact of the pandemic on their ability to cope with suicidal thoughts (e.g., âpandemic helped me to explore other ways to cope with suicidal thoughts and not depend on othersâ), three participants reported both a positive and negative impact of the pandemic on their coping with suicidal thoughts (e.g., âcould still see my close group of friends which was helpful, but when lockdowns cut access to going out to places, that made it harder to copeâ), and three participants reported perceiving the pandemic as having no effect on how they coped with suicidal thoughts (e.g., âI donât think it really changedâ). Aggregating SSC Interview Responses into SSC Dimensions. Responses to this interview were used to assess 3 dimensions of SSC: Frequency, Variety, and Perceived impact. Rather than simply add item scores to yield dimensions (e.g., adding all frequency ratings into a single frequency dimension), we recognized that both the coping literature and suicide literature suggest utility in classifying coping methods as adaptive or maladaptive (Stanley et al., 2021). 45 Therefore, before aggregating items to capture SSC dimensions, items were first classified accordingly to ultimately compute separate scales indexing adaptive and maladaptive coping. Given the absence of guidelines for what precisely constitutes âadaptiveâ versus âmaladaptiveâ coping with suicidal ideation, the following procedures were used. Clinical and research experts were consulted and asked to provide their expert ratings of the SSC items. Specifically, ratings were collected from five experts not involved with the dissertation, including two PhD level DBT clinical psychologists, two PhD level suicide researchers who are also involved in crisis work, and a senior Crisis Centre staff member. These experts were asked to code each of the 36 SSC items as adaptive or maladaptive. Items with super majority (agreement of 4+ ratings) were categorized as adaptive or maladaptive (see Appendix A for adaptive and maladaptive classification of items). Other items were left uncategorized. The Frequency dimension of SSC was quantified in two ways: first by examining the frequency endorsement for each individual SSC item, and second by summing the frequency scores for all adaptive items and all maladaptive items to create an Adaptive Frequency scale and Maladaptive Frequency scale. The Variety dimension of SSC was quantified by counting the overall number of adaptive responses (Adaptive Variety scale) and overall number of maladaptive coping responses used (Maladaptive Variety Scale), regardless of their frequency of use. This method of quantifying variety parallels that used in previous research examining coping variety (see Heffer & Willoughby, 2017). For the Variety computation, all SSC items were recoded as a 1 (âUsed at least oneâ) or a 0 (âNever usedâ) based on whether a participant reported ever using the item (i.e., all items with a score of 2 â âRarelyâ â or higher on the 5-point Likert frequency scale were coded as a 1, coping items with a score of 1 â âNeverâ â were coded as a 0). Following this, 46 adaptive items were summed and maladaptive items were summed to create two overall scores representing the Adaptive Variety scale and Maladaptive Variety scale. The Perceived impact dimension was quantified with a 5-point Likert scale rating the perceived impact of each SSC item on each facet of suicidal ideation (desire to die, desire to live, and suicide intent). Participants indicated whether each item was perceived to reduce their desire to die (4 = âdecreased somewhatâ; or 5 = âdecreased a lotâ), increase their desire to die (2 = âincreased somewhatâ; 1 = âincreased a lotâ), or have no perceived impact on their desire to die (3 = âabout the sameâ). This was repeated for perceived impact on desire to live and suicide intent. For ease of interpretation of results, scores for the desire to live facet of suicidal ideation were reverse coded, such that for all three facets of suicidal ideation, higher scores reflected perceived decrease in suicidal ideation, and lower scores reflected perceived increase in suicidal ideation. In addition, for each SSC item, an aggregate score of perceived impact on overall suicidal ideation was created by summing scores on the three facets of suicidal ideation. On this aggregate score of perceived impact on overall suicidal ideation, higher values reflected overall perceived decrease in suicidal ideation (i.e., decreased desire to die, increased desire to live, and decreased suicide intent), and lower values reflected overall perceived increase in suicidal ideation (i.e., increased desire to die, decreased desire to live, and increased suicide intent) of coping items. Demographics. A standard demographics form developed by the laboratory was used to collect information on age, gender, language, race and ethnicity, sexual orientation, household income, education, employment, and history of mental health treatment. This measure was the first to be administered during the interview. 47 Self-Injurious Thoughts and Behaviors Interview (SITBI; Nock et al., 2007). The SITBI is a comprehensive measure of suicidal ideation, plans, gestures, attempts, and NSSI. In the current study, six questions from the SITBI were used during the interview portion to assess suicidal ideation. Specifically, these items assessed lifetime history of suicidal ideation, lifetime history of suicide plans, age of first suicidal ideation, age of most recent suicidal ideation, intensity of worst-point suicidal ideation, and intensity of suicidal ideation on average. Questions about intensity of worst-point and average suicidal ideation were responded to using a 5-point Likert scale ranging from 0 (âlow/littleâ) to 4 (âvery much/severeâ). An additional seventh question was asked about the intensity of current suicidal ideation from the past week using the same response options (0 = âlow/littleâ, to 4 = âvery much/severeâ). These questions were administered following the demographics form and prior to the assessment of SSC responses in the interview in order to confirm inclusion criteria for the present study (i.e., history of lifetime suicidal ideation), to gather further information regarding suicide-history before completing the assessment of SSC responses, and to introduce the topic of suicidal ideation to the interview. Self-Report Measures. Beck Scale for Suicide Ideation (BSS; Beck & Steer, 1991). The BSS is a self-report measure which assesses current suicidal ideation. The BSS is composed of 19 items and participants respond to each item on a scale of 0 â 2 with varying descriptors for each item, with higher responses indicating greater suicidal ideation intensity. The first 5 items act as screener items, and the remaining items only completed by those who have a nonzero score on the sum of the first 5 items. The BSS is extensively used in research and has demonstrated robust psychometric properties (Batterham et al., 2015). Factor-analytic work suggests that the BSS assesses components beyond suicidal ideation, such as preparation, communication, and courage 48 to attempt suicide, and that factor analysis distinguishes ideation items from these other items (Beck et al., 1979; 1997; Dhingra et al., 2018). Because the focus of this dissertation is on suicidal ideation, the decision was made to only include BSS items capturing suicidal ideation. This decision aligns with recent suggestions about best practices for measurement of suicidal ideation (Christensen & Victor, in press). I summed the first 7 items for this purpose. There were two reasons for this choice. First, these seven items have been found to aggregate together and index suicidal ideation in previous work (Dhingra et al., 2018). Second, an exploratory Factor Analysis (EFA) in Study 2 of this dissertation (ns=330-390; see method section for Study 2) identified these items as forming a cohesive ideation factor. I did not conduct an independent EFA in the Study 1 sample, because guidelines for EFA recommend a ratio of 5â10 participants per item as the minimal threshold (Kyriazos, 2018), and the Study 1 sample was too small. Of note, the original data analytic plan for this dissertation assumed use of the full BSS. Therefore, as a robustness check against post-hoc researcher degrees of freedom, I also report results from key analyses using the full BSS score at the end of the results section. Social Desirability Scale (SDS; Stöber, 2001). The SDS is a 16-item self-report measure used to assess the extent to which someone is presenting themselves in a socially desirable way. Items are rated as true or false by participants. Past research finds that the SDS demonstrates good internal reliability (Cronbachâs as = .72 - .80) and correlates strongly with other measures of social desirability, moderately with personality factors of agreeableness and conscientiousness, and weakly with other personality factors of neuroticism, extraversion, and openness to experience (Stöber, 2001). Six items of the SDS are reverse scored, and all items summed for a total score, where higher scores indicate greater social desirability. This measure was chosen to assess the extent to which the endorsement of SSC responses may be associated 49 with tendencies for participants to present themselves in a socially desirable way given the in-person interview context. Suicide History. History of suicidal ideation and suicide attempt was assessed using a collection of 8 items drawn from various standardized sources, including the Youth Risk Behavior Survey Suicide Screening Questionnaire (YRBS; Brener et al., 2002; Kolbe et al., 1993), and the Suicide Attempt Self-Injury Interview (SASII; Linehan et al., 2006). Specifically, 6 items from the YRBS were used to assess lifetime history and recent (past 12-month) history of suicidal ideation, suicide plans, and suicide attempt. These items have demonstrated good reliability and validity in past research. Two items from the SASII were used to assess the medical severity of a lifetime history and recent (past 12-month) history of suicide attempts. These questions were included to provide information regarding the clinical severity of the present sample and to examine the relationship of coping to suicide attempt history. Suicide-Related Coping Scale (SRCS; Stanley et al., 2017). The Suicide-Related Coping Scale (SRCS; Stanley et al., 2017) is a 17-item self-report measure which assesses knowledge of and perceived self-efficacy in engaging in the use of coping responses and resources to manage suicidal ideation (see Appendix D). No timeframe is specified in the original version of this measure; however, for the present study a timeframe was added to specify that participants answer based on the most recent time they experienced suicidal ideation. All items were summed for a total score of SSC knowledge and confidence. Past research has identified a two factor structure (External Coping and Internal Coping; Stanley et al., 2017) and three factor structure (External Coping, Internal Coping, and Perceived control; Rainbow et al., 2023). Given this discrepancy in factor structure, and use of the total score in past research, the present study used the total score of the SRCS to capture the Knowledge/Confidence dimension of SSC. 50 Note Regarding Mid-Study Expansion of Measures. Initial data for this study were obtained from 11 participants using an early version of this study. At this point, three additions were made to the study: (1) the self-report measure of SSC which measures Knowledge/Confidence (i.e., SRCS, Stanley et al., 2017) was added, (2) an additional facet of suicidal ideation for Perceived impact was added (desire to live), (3) additional Likert scale options were added to questions assessing Perceived impact on suicidal ideation to include options for coping responses to increase desire to die or suicide intent (and likewise, decrease desire to live). Data on these additional measures and items were obtained from the remaining 89 participants. Data Analytic Plan Preliminary analyses examined descriptive statistics to assess normality of data and internal reliability of measures. Correlational analyses and t tests examined differences in SSC across demographic variables, social desirability, pre versus mid-pandemic participation, and psychiatric treatment history. Due to small ns in these subgroups, results should be interpreted with caution. In addition, only larger subgroups were compared (e.g., only differences between men and women were examined given there were n = 3 nonbinary and/or gender fluid participants). Research Question 1 (Study 1). Research question one examined which responses were used most and least often to cope with suicidal ideation. This was identified in two ways: mean endorsement, and the percentage of participants reporting that they used items commonly to cope with suicidal ideation. For this latter computation, the two highest scores on the Likert scale (i.e., 51 4 = âUsuallyâ or 5 = âAlwaysâ) were combined to form a category reflecting percentage of participants that often used that item to cope with suicidal ideation. Research Question 2 (Study 1). Research question two examined the Perceived impact dimension of SSC. Perceived impact on the three facets of suicidal ideation (i.e., desire to die, desire to live, and suicide intent) was examined using descriptive statistics. First, for each SSC item, means (and standard deviations) of responses to each facet of suicidal ideation were examined. Second, for each SSC item, means (and standard deviations) for the sum score of three impact scores (desire to die, desire to live, and suicide intent) were examined. Higher means reflect perceiving the coping item to decrease suicidal ideation and lower means reflect perceiving the coping item to increase suicidal ideation. Third, percentages are reported to capture the proportion of participants who reported perceiving each SSC item to increase, decrease, or have no impact, on each facet of suicidal ideation. In order to facilitate interpretation of data, responses that indicated increasing suicidal ideation (1 and 2) and responses that indicated decreasing suicidal ideation (4 and 5) on the 5-point Likert scale for each facet of suicidal ideation were combined to form 3 categories of perceived impact: Reduced suicidal ideation, No change, and Increased suicidal ideation. Research Question 3 (Study 1). Research question three examined the cross-sectional relationships between SSC dimensions and suicide-related variables (i.e., current suicidal ideation, worst-point ideation, and history of suicide attempts) using Pearsonâs and point biserial correlation coefficients and p values. These associations were also examined for each individual SSC item. 52 Power analysis Given the descriptive nature of research questions one and two, power analysis for Study 1 focused on analyses for research question three which examine Pearsonâs correlations (between SSC and suicidal ideation variables) and point biserial correlations (between SSC and lifetime history of suicide attempt). Power analyses were conducted using G*Power 3.1.9.6 (Faul et al., 2009) to determine the smallest effect size expected to detect give the sample size collected. With 102 participants, there was 80% power to detect a correlation of r = .27 (alpha set at .05, two-tailed). No previous study has examined Frequency and Variety of SSC. Thus, the relationship of these variables to suicidal ideation and attempts has never been examined. However, the Knowledge/Confidence dimension of SSC (using the SRCS, Stanley et al., 2017) has been examined. A range of moderate to large effect sizes are reported in previous research between the SRCS and current suicidal ideation (Stanley et al., 2017: r = -.30), past week suicidal ideation (Interian et al., 2021: r = -.48), past four-week suicidal ideation (Rainbow et al., 2023: r = -.52, r = -.54), and intensity of worst point suicidal ideation (Stanley et al., 2017: r = -.25; Interian et al., 2021: r = -.38). Small effect sizes are reported between the SRCS and lifetime suicide attempts (Interian et al., 2021: r = -.25; Rainbow et al., 2023: rs = -.11 â -.24; Stanley et al., 2017: r = -.12). Based on these findings, the present sample size was expected to be slightly underpowered to detect small effects, and sufficiently powered to detect effect sizes in moderate to large ranges. 53 Study 1 Results Preliminary Considerations As discussed earlier, there is a notable lack of empirical research examining SSC. As a result, a primary aim of this dissertation was to provide rich descriptive data about a variety of coping responses that can help develop basic knowledge about SSC and serve as a basis for other researchers to generate hypotheses and study ideas. Given that various analyses in Study 1 involved individual measure items, in addition to scales/dimensions, many analyses were conducted and reported in the sections to follow. This analytical approach is suitable for exploratory research (Althouse, 2016) and useful for âhypothesis generatingâ (as opposed to âhypothesis testingâ) research (Streiner, 2015). Hypotheses were reserved for the correlational analyses examining associations between SSC dimensions and suicidal ideation and attempts. Given the large number of analyses conducted, it is important to recognize and hold in mind the increased probability of finding effects that are poor estimates of true population parameters. For this reason, full analyses and results are reported to enable accurate interpretation maximize utility of findings for future research (Greenland et al., 2016; Wasserstein & Lazar, 2016). Data Preparation 102 participants completed Study 1. Among these, 34 participants had some amount of missing data for the following reasons: the first 11 study participants completed an initial version of the study that did not include an item about Perceived impact on desire to live, did not include a Likert scale response option to indicate SSC items were perceived to increase suicidal ideation 54 (and only included options for suicidal ideation to decrease or stay the same), and did not include the SRCS, the self-report measure which captures Knowledge/Confidence dimension (see methods for more details); 12 participants indicated that for some SSC items, the Perceived impact was âvariableâ (e.g., sometimes it increased desire to die, but sometimes it decreased desire to die) and thus did not provide a rating for Perceived impact on that facet of ideation; eight participants reported that they did not remember whether they had used an item or did not remember the Perceived impact of the item on facets of suicidal ideation; five participants were missing data on certain items because the study ran over time and not all interview items could be administered; one participant withdrew from the study partway into the interview due to not wishing to speak about their experiences with SSC; one participant did not complete the online portion due to reporting a moderate to high level of suicide risk during the interview and a suicide risk assessment conducted during the remaining study time; one participant was missing data for the interview portion due to a technical error; one participant skipped an interview item (lifetime history of plan for suicide) because they preferred not to answer. Therefore, sample size for SSC item responses ranged from 94 â 101; the ns for each SSC item and follow-up items for Perceived impact are reported alongside results in the tables below (see Tables 4 â 7). Missing data meant that Frequency and Variety scales could not be computed for all participants. Items relevant for the Adaptive Frequency and Adaptive Variety scales were missing for 10 participants; however, for four participants, the amount of missing data were small (i.e., <8%; Bennett, 2001; Jakobsen et al., 2017) and thus zeroes were imputed for missing data when computing the Adaptive Frequency and Variety scales. The remaining 6 participants were missing >15% of data from adaptive items and thus coded as missing data for these scales. 55 Items relevant for Maladaptive Frequency and Variety scales were missing data for 2 participants and coded as missing for these scales. Preliminary Analyses Clinical Characteristics. Clinical characteristics of the sample are reported below in Table 2. Overall, 65% of participants reported non-zero current suicidal ideation (as assessed by the BSS; Beck & Steer, 1991). Over half of the sample reported making a plan for suicide in their lifetime (61%) and approximately one third reported a suicide attempt history in their lifetime (35%). 56 Table 2 Study 1 clinical characteristics Variables n % Ever received mental health treatment Yes 66 65% No 35 35% Number of visits for mental health 0 visits 35 35% 1 â 9 visits 19 19% 10 â 49 visits 20 20% 50 â 99 visits 12 12% 100 â 499 visits 11 11% 500 â 999 visits 2 2% > 1,000 visits 2 2% Mean (SD) Range Suicidal ideation Age of first-time SI 15.08 (3.23) 6 â 23 Age of last-time SI 19.87 (4.03) 13 â 41 Average intensity SI (lifetime) 2.29 (0.84) 0 â 4 Worst point SI (lifetime) 3.35 (0.71) 0 â 4 Average past week SI 0.49 (0.82) 0 â 4 n % Lifetime history of plan for suicide Yes 62 62% No 38 38% Lifetime history suicide attempt Yes 35 35% No 65 65% Suicide attempt required medical treatment Yes 11 31% No 24 69% Past 12 months plan for suicide Yes 16 16% No 84 84% Past 12 months suicide attempt Yes 7 8% No 85 92% Suicide attempt (past 12 months) required medical treatment Yes 0 0% No 7 100% Note. SI = suicidal ideation. Sample size for clinical information ranges from 100-101 due to missing data for some participants. 57 Normality of data and psychometrics. Descriptive statistics for key variables are reported in Table 3 below. All variables demonstrated normal distribution, with the exception of suicidal ideation (Skewness = 1.93, Kurtosis = 3.75). All scales had adequate internal reliability with the exception of the Maladaptive Frequency scale and the Maladaptive Variety scale. There are at least two likely explanations for the low internal reliability for the maladaptive SSC scales: 1) the sum of maladaptive coping methods may best be conceptualized as a formative (not reflective) variable (Bollen & Lennox, 1991); 2) they consist of only three items, which constrains the magnitude of coefficient alpha (Tavakol & Dennick, 2011). Table 3 Descriptive statistics for Study 1 key variables Variables Mean (SD) Range Skewness Kurtosis a n Current Suicidal Ideation 2.12 (2.82) 0 â 13 1.93 3.75 .89 100 Adaptive Frequency scale 58.34 (13.16) 33 â 100 0.51 0.20 .80 96 Maladaptive Frequency scale 7.92 (2.05) 3 â 13 -0.13 -0.14 .22 100 Adaptive Variety scale 14.42 (4.78) 4 â 25 -0.08 -0.40 .79 96 Maladaptive Variety scale 2.10 (0.78) 0 â 3 -0.43 -0.53 .22 100 Knowledge/Confidence 61.68 (11.49) 35 â 83 -0.32 -0.38 .85 89 Note. Current suicidal ideation measured using the first 7 items of the Beck Scale for Suicide Ideation. Suicide-specific coping scales are created from summing adaptive and maladaptive items from interview administered items (see Appendix A). Items for Adaptive and Maladaptive scales differ from items used for these scales in Study 2. Knowledge/Confidence measured using the Suicide-Related Coping Scale (Stanley et al., 2017). Differences Across Participant Characteristics. Differences in SSC dimensions across demographic variables, pre-post pandemic participation, social desirability, and psychiatric treatment history were examined. To increase statistical power, multiple categories within a demographic variable were collapsed. For example, for sexual orientation, categories of 58 âstraightâ and ânot straightâ were created, with ânot straightâ combining different sexual orientations including bisexual, gay, questioning, lesbian, and others. Although this decision maximizes size of subgroups for analyses, it ignores differences between each of these identifies, and thus is a limitation of these analyses. No meaningful differences emerged across age, gender, sexual orientation, yearly household income, or current employment status. When comparing participants of East Asian descent with White/European participants, differences emerged with White/European participants reporting greater scores on Adaptive Frequency (d=0.64, p=.02) and Maladaptive Frequency (d=0.59, p=.02) scales. Similar differences were found across primary language, with those who reported English as their primary language reporting greater scores on Adaptive Frequency (d=0.79, p<.001) and Adaptive Variety (d=0.64, p=.005) scales, and Knowledge/Confidence (d=0.59, p=.01). When examining differences in SSC dimensions for participants who participated pre versus post pandemic, differences were observed for the Variety dimension. Participants who participated in the study during the pandemic reported greater scores on the Adaptive Variety (d=0.56, p=.01) and Maladaptive Variety (d=0.52, p=.01) scales. In other words, participants who participated during the pandemic reported using a greater overall number of different coping responses compared to participants who participated before the pandemic began, although there were no differences observed in terms of frequency of use. Participants who reported a history of at least some mental health treatment reported greater scores on Adaptive Frequency (d=0.42, p=.05), Maladaptive Frequency (d=0.95, p<.001), Adaptive Variety (d=0.63, p=.004), and Maladaptive Variety (d=0.81, p<.001) scales. Social desirability did not appear to be associated with any SSC dimensions (rs = |.06 - .15|, ps > .16). 59 Research Question 1 (Study 1): Frequency of SSC Responses Research question 1 examined which responses were used most and least often to cope with suicidal ideation. Table 4 presents the frequency data for 36 difference possible SSC responses â including means, standard deviations (SDs), and percentages for each SSC item. While data reported in Table 4 are detailed and comprehensive, I summarize some key results and patterns below. Examining the means of each SSC item revealed that the five most often used items were: Anticipating othersâ reactions if you were to act on your suicidal thoughts (mean=3.94), Withdrawing from others and staying alone (mean=3.79), Thinking about reasons for living or staying alive (mean=3.50), Thinking about how painful or scary it would be to act on suicidal thoughts (mean=3.46), and Watching or listening to a sad movie/music (mean=3.25). Examining the percentage of participants who reported using items often (âusuallyâ or âalwaysâ when suicidal) revealed that half the sample or more reported using the following items often: Withdrawing from others and staying alone (71%), Anticipating othersâ reactions if you were to act on your suicidal thoughts (67%), Thinking about how painful or scary it would be to act on suicidal thoughts (58%), and Thinking about reasons for living or staying alive (50%). Examining the means of each SSC item revealed that the five least often used items were: Going to the hospital (mean=1.24), Cooking or baking (mean=1.26), Using an app designed for coping (mean=1.26), Taking a psychiatric medication (mean=1.26), and Contacting a crisis center or help line (mean=1.39). Examining the percentage of participants who reported using items often (âusuallyâ or âalwaysâ) revealed that less than 10% of participants used the following items often: Going to the hospital (0%), Cooking or baking (1%), Using an app designed for coping (1%), Contacting a crisis center or help line (1%), Means safety (6%), 60 Taking a psychiatric medication (7%), Using strong sensations for grounding (e.g., ice, cold water; 7%), Using a safety plan (8%), and Being around other people (9%). 61 Table 4 Study 1 Research Question 1: Frequency of suicide-specific coping items (means, SDs, and percentages) Suicide-specific coping item n Mean (SD) % used often 27. Anticipating othersâ reactions if you were to act on your suicidal thoughts 100 3.94 (1.11) 67% 12. Withdrawing from others and staying alone 101 3.79 (1.00) 71% 19. Thinking about reasons for living or staying alive 101 3.50 (1.13) 50% 30. Thinking about how painful or how much it would hurt or how scary it would be 100 3.46 (1.44) 58% 10. Watching a movie/TV show/listening to music that is sad 100 3.25 (1.29) 46% 36. Going to sleep/taking a nap 97 3.18 (1.41) 46% 2. Talking with a friend or family member but not mentioning suicidal thoughts 101 3.08 (1.21) 40% 15. Finding someone who is understanding 101 2.92 (1.29) 34% 17. Keeping busy (e.g., doing school work, work, cleaning, errands) 100 2.92 (1.36) 35% 25. Engaging in a positive activity (e.g., hobby, games, spent time outside, etc) 99 2.79 (1.29) 30% 21. Thinking about things in the future you are looking forward to 100 2.69 (1.21) 25% 29. Going on social media (e.g., Instagram, Facebook, Snapchat, etc) 99 2.65 (1.44) 33% 22. Being around friends 98 2.56 (1.32) 26% 9. Watching a movie/TV show/listening to music that is happy 100 2.55 (1.29) 25% 20. Thinking about good memories 98 2.52 (1.29) 24% 1. Talking with a friend or family member and mentioning your suicidal thoughts 101 2.44 (1.22) 23% 8. Exercising or engaging in recreational physical activity 101 2.42 (1.23) 25% 24. Making meaning out of the situation 98 2.35 (1.36) 24% 28. Thinking about others with similar problems 98 2.33 (1.15) 16% 33. Taking a hot bath or shower 96 2.26 (1.20) 19% 3. Engaging in self-harm without intending to die 100 2.17 (1.14) 13% 6. Talking with a therapist or health professional 101 2.14 (1.22) 18% 23. Being around people 98 2.06 (1.11) 9% 13. Engaging in meditation or relaxation exercises or mindfulness 101 2.01 (1.14) 11% 11. Going to a public place (e.g., coffee shop, park) 101 1.97 (1.09) 11% 16. Using substances (e.g., alcohol, non-prescription drugs) 101 1.95 (1.13) 12% 26. Playing music (e.g., guitar, piano) 99 1.95 (1.30) 17% 18. Turning to religion or spirituality 101 1.88 (1.34) 17% 7. Using a safety plan 101 1.50 (1.07) 8% 35. Removing the means that could be used from home or reducing ease of access 99 1.43 (0.92) 6% 14. Use sensation to ground (e.g. cold shower, ice, strong smell) 101 1.40 (0.92) 7% 4. Calling a crisis center or help line 101 1.39 (0.65) 1% 32. Taking a psychiatric medication 94 1.36 (1.06) 7% 31. Using an app on your phone designed for coping 94 1.26 (0.67) 1% 34. Cooking 94 1.26 (0.65) 1% 5. Going to the hospital 101 1.24 (0.51) 0% Note. Items ordered from most to least frequently used by mean. Frequency ratings range from 1 (âneverâ) to 5 (âalwaysâ). Percentage of participants âused oftenâ computed by summing proportion who reported using item âusuallyâ or âalwaysâ. Item content shortened for brevity; full item content reported in Appendix A. Sample size varies (ns range 94 â 101) due to missing data for some items, see data preparation section. Research Question 2 (Study 1): Perceived Impact of SSC Responses Research question 2 explored the Perceived impact of SSC items on suicidal ideation. I first examined Perceived impact of SSC items on each facet of suicidal ideation: desire to die, desire to live, and suicide intent. Scoring procedures for Perceived impact were described in methods section. As a reminder, Perceived impact on suicidal ideation was rated using the following scale: 1 = âincreased a lotâ, 2 = âincreased somewhatâ, 3 = âstayed about the sameâ, 4 = âdecreased somewhatâ, 5 = âdecreased a lotâ. This scale was reverse coded for desire to live, such that across each facet, higher scores reflected perceiving the item to reduce suicidal ideation, and lower scores reflected perceiving the item to increase suicidal ideation. Table 5 displays the full data for perceived impact of SSC items, including means (and SDs) for each item. I summarize key results below. Regarding perceived impact on desire to die, the following items were perceived to decrease this facet of ideation the most: Finding someone understanding (mean=4.24), Exercising/engaging in physical activity (mean=4.10), and Being around friends (mean=3.87). Items perceived to increase desire to die the most were: Withdrawing from others (mean=2.21), Watching or listening to a sad movie/music (mean=2.70), and Using social media (mean=2.78). Items perceived to increase desire to live the most were: Finding someone understanding (mean=3.94), Being around friends (mean=3.94), and Thinking about reasons for living (mean=3.90). Items perceived to decrease desire to live the most were: Withdrawing from others (mean=2.34), Using substances (mean=2.72), and Engaging in NSSI (mean=2.75). Items perceived to decrease suicide intent the most were: Using a safety plan (mean=4.27), Means safety (mean=4.23), and Finding someone understanding (mean=4.11). 63 Items perceived to increase suicide intent the most were: Engaging in NSSI (mean=1.38), Withdrawing from others (mean=2.61), and Using substances (mean=3.06). 64 Table 5 Study 1 Research Question 2: Perceived impact of suicide-specific coping items on desire to die, desire to live, and suicide intent Suicide-specific coping item na Desire to die Desire to live Suicide intent Mean (SD) n Mean (SD) n Mean (SD) n 1. Talk with a friend/family member and mentioning suicidal thoughts 74 3.68 (0.83) 74 3.53 (0.74) 70 3.85 (0.87) 74 2. Talk with a friend/family member but not mentioning suicidal thoughts 87 3.64 (0.70) 87 3.60 (0.71) 78 3.64 (0.77) 86 3. Engage in self-harm without intending to die 64 2.97 (0.78) 64 2.75 (0.64) 56 1.38 (0.89) 63 4. Call a crisis center or help line 31 3.03 (0.95) 31 3.00 (0.87) 30 3.45 (0.77) 31 5. Go to the hospital 20 3.37 (1.16) 19 3.47 (1.33) 17 3.95 (1.18) 19 6. Talking with a therapist or health professional 56 3.85 (0.89) 55 3.58 (0.77) 48 4.05 (0.80) 55 7. Using a safety plan 22 3.86 (0.77) 22 3.37 (0.68) 19 4.27 (0.77) 22 8. Exercising or engaging in recreational physical activity 67 4.10 (0.72) 67 3.64 (0.74) 59 3.87 (0.80) 67 9. Watching a movie/TV show/listening to music that is happy 69 3.59 (0.61) 66 3.39 (0.64) 62 3.54 (0.70) 67 10. Watching a movie/TV show/listening to music that is sad 84 2.70 (0.99) 82 2.89 (0.67) 74 3.12 (0.73) 82 11. Going to a public place (e.g., coffee shop, park) 53 3.65 (0.81) 52 3.47 (0.71) 49 3.68 (0.78) 53 12. Withdrawing from others and stay alone 97 2.21 (0.87) 95 2.34 (0.73) 85 2.61 (0.83) 95 13. Engaging in meditation or relaxation exercises or mindfulness 52 3.60 (0.69) 52 3.42 (0.58) 48 3.67 (0.65) 52 14. Use sensation to ground (e.g. cold shower, ice, strong smell) 19 3.63 (0.60) 19 3.10 (0.81) 19 3.74 (0.81) 19 15. Finding someone who is understanding 80 4.24 (0.77) 79 3.94 (0.77) 72 4.11 (0.83) 80 16. Using substances (e.g., alcohol, non-prescription drugs) 50 2.86 (1.08) 49 2.72 (0.91) 43 3.06 (1.08) 50 17. Keeping busy (e.g., doing school work, cleaning, errands) 77 3.44 (0.90) 77 3.25 (0.72) 68 3.64 (0.86) 77 18. Turning to religion or spirituality 36 3.75 (1.00) 36 3.79 (0.99) 33 3.83 (0.77) 36 19. Thinking about reasons for living or staying alive 96 3.84 (0.90) 95 3.90 (0.95) 84 3.88 (0.86) 95 20. Thinking about good memories 66 3.67 (0.91) 64 3.72 (0.75) 57 3.61 (0.83) 64 21. Thinking about things in the future you are looking forward to 77 3.80 (0.81) 74 3.94 (0.79) 65 3.79 (0.83) 75 22. Being around friends 68 3.87 (0.77) 68 3.72 (0.67) 57 3.94 (0.86) 68 23. Being around people 54 3.41 (0.69) 54 3.29 (0.58) 48 3.54 (0.74) 54 24. Making meaning out of the situation 55 3.58 (0.82) 52 3.56 (0.78) 46 3.50 (0.75) 52 25. Engaging in a positive activity (e.g., hobby, games) 76 3.86 (0.83) 76 3.60 (0.74) 67 3.78 (0.81) 76 26. Playing music (e.g., guitar, piano) 42 3.71 (0.83) 42 3.59 (0.60) 37 3.67 (0.69) 42 27. Anticipate othersâ reactions if you were to act on your suicidal thoughts 97 3.75 (1.01) 97 3.43 (0.99) 86 3.97 (1.00) 97 28. Thinking about others with similar problems 65 3.36 (0.82) 64 3.10 (0.72) 57 3.41 (0.83) 64 29. Going on social media (e.g., Instagram, Facebook, Snapchat) 65 2.78 (0.86) 60 2.82 (0.71) 57 3.17 (0.75) 63 30. Thinking about how painful or scary it would be 86 3.79 (0.83) 86 3.21 (0.67) 77 4.09 (0.89) 86 31. Using an app on your phone designed for coping 15 3.53 (0.64) 15 3.33 (0.49) 12 3.80 (0.68) 12 65 32. Taking a psychiatric medication 12 3.75 (0.87) 12 3.30 (0.48) 10 4.08 (0.90) 12 33. Taking a hot bath or shower 59 3.44 (0.57) 57 3.23 (0.51) 51 3.52 (0.68) 58 34. Cooking 14 3.57 (0.65) 14 3.75 (0.45) 12 3.71 (0.91) 14 35. Remove means that could be used from home or reducing ease of access 22 3.23 (0.61) 22 3.10 (0.31) 20 4.23 (0.81) 22 36. Going to sleep/taking a nap 75 3.49 (0.83) 73 2.98 (0.68) 63 3.52 (0.91) 73 Note. Means range from 1 - 5 (1= âincreased a lotâ, 2= âincreased somewhatâ, 3= âstay about the sameâ, 4= âdecreased somewhatâ, 5= âdecreased a lotâ; desire to live reverse coded). Higher values indicate perceived decrease in desire to die and suicide intent, and increase in desire to live. Sample size varies for responses due to missing data; see data preparation section. Item content shortened for brevity; full item content reported in Appendix A. an reported indicates number of participants who reported using each item at least once and thus were asked about perceived impact of item. Next, responses on each facet of suicidal ideation (desire to die, desire to live, suicide intent) were summed to create a variable capturing overall perceived impact on suicidal ideation. Total scores ranged from 3 â 15, with higher scores indicating that the item was perceived to reduce suicidal ideation. Cronbachâs a was examined for this aggregate score to assess the extent to which perceived impact on these facets of suicidal ideation reflected a similar underlying construct. With only three items in the scale, sample size recommendations for 80% power to detect a Cronbachâs a of at least .50 were estimated to be n=52 (Bujang et al., 2018). Due to low endorsement of certain SSC responses, I only calculated Cronbachâs a for SSC responses where more than 52 participants endorsed using the item at least once and therefore answered items about perceived impact (see Table 6 for n endorsing use of each item at least once). The Cronbachâs a for the aggregate score of Perceived impact on suicidal ideation ranged from .59 to .85 (median=.74) for SSC responses, suggesting that perceived impact on these three facets of suicidal ideation were related to one another. Table 6 presents the means (and SDs) of these aggregated scores for all SSC items. Items perceived to decrease overall suicidal ideation the most were: Finding someone understanding (mean=12.35), Exercising/engaging in physical activity (mean=11.58), Thinking about reasons for living (mean=11.56), Using a safety plan (mean=11.47), and Being around friends (mean=11.46). Items perceived to decrease suicidal ideation the least were: Withdrawing from others (mean=6.98), Using substances (mean=8.42), Watching or listening to a sad movie/music (mean=8.55), Going on social media (mean=8.75), and Engaging in NSSI (mean=9.04).67 Table 6 Study 1 Research Question 2: Perceived impact of suicide-specific coping on overall suicidal ideation Suicide-specific coping item na Perceived impact on suicidal ideation Mean (SD) 15. Finding someone who is understanding 72 12.35 (1.91) 8. Exercising or engaging in recreational physical activity 59 11.58 (1.72) 19. Thinking about reasons for living or staying alive 84 11.56 (2.26) 7. Using a safety plan 19 11.47 (1.54) 22. Being around friends 57 11.46 (1.92) 21. Thinking about things in the future you are looking forward to 65 11.43 (2.16) 6. Talking with a therapist or health professional 48 11.42 (2.17) 18. Turning to religion or spirituality 33 11.27 (2.10) 27. Anticipate othersâ reactions if you were to act on your suicidal thoughts 86 11.13 (2.44) 32. Taking a psychiatric medication 10 11.10 (1.73) 25. Engaging in a positive activity (e.g., hobby, games, etc) 67 11.09 (1.92) 30. Thinking about how painful or scary it would be 77 11.05 (1.83) 1. Talk with a friend/family member and mentioning suicidal thoughts 70 11.01 (1.91) 34. Cooking 12 10.92 (1.38) 20. Thinking about good memories 57 10.89 (2.15) 2. Talk with a friend/family member but not mentioning suicidal thoughts 77 10.88 (1.73) 26. Playing music (e.g., guitar, piano) 37 10.86 (1.38) 11. Going to a public place (e.g., coffee shop, park) 49 10.73 (1.74) 5. Going to the hospital 17 10.71 (3.39) 13. Engaging in meditation or relaxation exercises or mindfulness 48 10.60 (1.39) 35. Remove means that could be used from home or reducing ease of access 20 10.60 (1.35) 31. Using an app on your phone designed for coping 12 10.58 (1.68) 14. Use sensation to ground (e.g. cold shower, ice, strong smell) 19 10.47 (1.61) 9. Watching a movie/TV show/listening to music that is happy 60 10.45 (1.42) 24. Making meaning out of the situation 46 10.43 (1.88) 23. Being around people 48 10.29 (1.71) 17. Keeping busy (e.g., doing school work, work, cleaning, errands) 68 10.22 (1.93) 33. Taking a hot bath or shower 51 10.14 (1.28) 36. Going to sleep/taking a nap 63 9.90 (2.03) 28. Thinking about others with similar problems 57 9.77 (2.04) 4. Calling a crisis center or help line 30 9.43 (2.19) 3. Engaging in self-harm without intending to die 55 9.04 (1.89) 29. Going on social media (e.g., Instagram, Facebook, Snapchat, etc) 56 8.75 (2.07) 10. Watching a movie/TV show/listening to music that is sad 74 8.55 (1.97) 16. Using substances (e.g., alcohol, non-prescription drugs) 43 8.42 (2.53) 12. Withdrawing from others and staying alone 84 6.98 (2.02) Note. Items ordered from most to least perceived reduction in suicidal ideation. Perceived impact on overall suicidal ideation variable created by summing responses to perceived impact on three facets of suicidal ideation: desire to die, desire to live, and suicide intent. Higher values indicate greater perceived reduction in suicidal ideation. See data preparation section for missing data explanation. Item content shortened for brevity; full item content reported in Appendix A. an reported indicates number of participants who reported using item at least once and were thus asked about perceived impact of item, and had complete data on each facet of suicidal ideation 68 Finally, Perceived impact of SSC responses on each facet of suicidal ideation (desire to die, desire to live, suicide intent) was examined by reporting percentage of participants rating the perceived impact of items as decreasing, increasing, or having no perceived impact on ideation. These categories were created by summing responses to the 5-point Likert scale indicating a participant perceived the item to decrease suicidal ideation (4= âdecrease somewhatâ, 5= âdecrease a lotâ), increase suicidal ideation (2= âincrease somewhatâ, 1= âincrease a lotâ), or have no perceived impact (3= âabout the sameâ). Full results are reported in Table 7. A number of items were perceived to reduce desire to die for the majority of participants; items with the highest proportion of participants were: Finding someone understanding (87%) and Exercising/engaging in recreational physical activity (79%). One item was perceived to increase desire to die for the majority of participants: Withdrawing from others (62%). A number of items were perceived to increase desire to live for the majority of participants; items with the highest proportion of participants were: Finding someone understanding (76%), Thinking about things in future you are looking forward to (75%), Cooking or baking (75%), and Thinking about reasons for living (70%). The item perceived to decrease desire to live for the majority of participants was: Withdrawing from others (58%). A number of items were perceived to reduce suicide intent for the majority of participants; items with the highest proportion of participants were: Using a safety plan (82%), Going to the hospital (79%), Means safety (77%), Finding someone understanding (74%), Thinking about how painful or scary acting on suicidal thoughts would be (72%), and Talking with a therapist/health professional (71%). No items were perceived to increase suicide intent for the majority of participants, however, the items perceived to increase intent by the most participants were: Withdrawing from others (43%) and Using substances (30%). 69 Table 7 Study 1 Research Question 2: Perceived impact of suicide-specific coping in percentages on desire to die, desire to live, and suicide intent Suicide-specific coping item na Desire to die Desire to live Suicide intent Decreased No effect Increased Increased No effect Decreased Decreased No effect Increased 1. Talking with a friend or family member and mentioning suicidal thoughts 74 62% 31% 7% 50% 44% 6% 64% 34% 3% 2. Talking with a friend or family member but not mentioning suicidal thoughts 87 54% 45% 1% 53% 45% 3% 51% 47% 2% 3. Engaging in self-harm without intending to die 64 23% 50% 27% 11% 54% 36% 46% 37% 17% 4. Calling a crisis center or help line 31 32% 42% 26% 27% 57% 17% 52% 42% 6% 5. Going to the hospital 20 58% 21% 21% 47% 35% 18% 79% 5% 16% 6. Talking with a therapist or health professional 56 67% 25% 7% 54% 40% 6% 71% 29% 0% 7. Using a safety plan 22 64% 36% 0% 37% 58% 5% 82% 18% 0% 8. Exercise/engage in recreational physical activity 67 79% 21% 0% 52% 46% 2% 61% 39% 0% 9. Watch happy movie/TV show/listening to music 69 53% 47% 0% 37% 60% 3% 42% 58% 0% 10. Watch sad movie/TV show/listening to music 84 18% 41% 40% 15% 62% 23% 24% 61% 15% 11. Going to a public place (e.g., coffee shop, park) 53 60% 33% 8% 47% 47% 6% 57% 40% 4% 12. Withdrawing from others and staying alone 97 6% 32% 62% 3% 39% 58% 12% 45% 43% 13. Engaging in meditation, relaxation, mindfulness 52 52% 46% 2% 42% 56% 2% 58% 42% 0% 14. Use sensation to ground (e.g. cold shower, ice) 19 58% 42% 0% 32% 53% 16% 63% 32% 5% 15. Finding someone who is understanding 80 87% 9% 4% 76% 19% 4% 74% 25% 1% 16. Use substances (alcohol, non-prescription drugs) 50 26% 39% 35% 16% 47% 37% 36% 34% 30% 17. Keep busy (e.g., doing school work, cleaning) 77 48% 40% 12% 31% 60% 9% 49% 45% 5% 18. Turning to religion or spirituality 36 61% 31% 8% 64% 24% 12% 61% 39% 0% 19. Think about reasons for living or staying alive 96 67% 24% 8% 70% 21% 8% 61% 37% 2% 20. Think about good memories 66 69% 20% 11% 65% 30% 5% 48% 47% 5% 21. Think about things in future looking forward to 77 68% 28% 4% 75% 20% 5% 59% 39% 3% 22. Being around friends 68 33% 28% 3% 60% 40% 0% 63% 35% 1% 23. Being around people 54 37% 59% 4% 31% 65% 4% 46% 50% 4% 24. Making meaning out of the situation 55 56% 35% 10% 57% 35% 9% 46% 48% 6% 25. Engage in positive activity (e.g., hobby, games) 76 67% 30% 3% 54% 42% 4% 59% 38% 3% 26. Playing music (e.g., guitar, piano) 42 57% 38% 5% 54% 46% 0% 55% 45% 0% 27. Anticipating othersâ reactions if you were to act on your suicidal thoughts 97 61% 29% 10% 43% 44% 13% 67% 27% 6% 28. Thinking about others with similar problems 65 39% 53% 8% 26% 63% 11% 39% 53% 8% 70 Suicide-specific coping item na Desire to die Desire to live Suicide intent Decreased No effect Increased Increased No effect Decreased Decreased No effect Increased 29. Go on social media (e.g., Instagram, Snapchat) 65 20% 47% 33% 9% 68% 23% 30% 56% 14% 30. Thinking about how painful or scary it would be 86 63% 33% 5% 25% 66% 9% 72% 24% 3% 31. Using an app on your phone designed for coping 15 47% 53% 0% 33% 67% 0% 67% 33% 0% 32. Taking a psychiatric medication 12 50% 50% 0% 30% 70% 0% 67% 33% 0% 33. Taking a hot bath or shower 59 47% 49% 3% 24% 75% 2% 45% 53% 2% 34. Cooking 14 50% 50% 0% 75% 25% 0% 43% 57% 0% 35. Removing means that could be used from home or reducing ease of access 22 23% 73% 4% 10% 90% 0% 77% 23% 0% 36. Going to sleep/taking a nap 75 52% 40% 8% 16% 68% 16% 41% 52% 7% Note. Decreased percentages computed by combining responses âdecreased a lotâ and âdecreased somewhatâ; Increased percentages computed by combining responses âincreased somewhatâ and âincreased a lotâ. See results section for explanation of missing data. Item content shortened for brevity; full item content is reported in the Appendix A. Desire to live data are shaded for ease of interpretation. an reported indicates number of participants who reported using item at least once and thus were asked about perceived effect of item. 69 Research Question 3 (Study 1): Association of SSC with Suicidal Ideation and Attempts Research question three examined the relationship between SSC and current suicidal ideation intensity, worst-point suicidal ideation, and history of suicide attempts. These relationships were first examined for individual SSC items and are reported below in Table 8. Across all suicide-related variables (current ideation, worst-point ideation, and attempt history), correlations for individual SSC items ranged from negligible to moderate in strength (rs = |.001 - .32|). The SSC items with the strongest associations with current suicidal ideation were: Thinking about reasons for living (r = -.25, p = .01) and Contacting a crisis center (r = .21, p = .04). The items with the strongest associations with worst point ideation were: Going to the hospital (r = .32, p < .001), Contacting a crisis center (r = .25, p = .01), and Withdrawing from others (r = .24, p = .01). The items with the strongest associations with history of suicide attempts were: Contacting a crisis center (r = .31, p =.002), Going to the hospital (r = .27, p =.007), Engaging in a positive activity (r = .27, p =.008), Means safety (r = .23, p = .02), Anticipating othersâ reactions if you were to act on suicidal thoughts (r = .22, p = .03), Make meaning (r = .22, p =.03), and Thinking of good memories (r = .21, p = .04). 70 Table 8 Study 1 Research Question 3: Correlations between suicide-specific coping items and current suicidal ideation, worst-point ideation, and suicide attempt history Suicide-specific coping item Current SI Worst-point SI SA historya 1. Talk with a friend/family member and mentioning suicidal thoughts -.04 -.003 .09 2. Talk with a friend/family member but not mentioning suicidal thoughts .01 .003 .03 3. Engaging in self-harm without intending to die .03 .19 .18 4. Calling a crisis center or help line .21 .25 .31 5. Going to the hospital .04 .32 .27 6. Talking with a therapist or health professional .02 .19 .20 7. Using a safety plan -.09 .16 .10 8. Exercising or engaging in recreational physical activity .02 .11 .15 9. Watching happy movie/TV show/listening to music .18 .03 .18 10. Watching sad movie/TV show/listening to music .08 .05 .05 11. Going to a public place (e.g., coffee shop, park) .01 -.10 .16 12. Withdrawing from others and staying alone .17 .24 .07 13. Engaging in meditation, relaxation, mindfulness -.15 .07 .15 14. Use sensation to ground (e.g. cold shower, ice) .16 .17 .14 15. Finding someone who is understanding -.16 -.14 .11 16. Using substances (e.g., alcohol, recreational drugs) .13 .15 .02 17. Keeping busy (e.g., doing work, cleaning, errands) .06 -.06 .08 18. Turning to religion or spirituality -.19 -.20 -.11 19. Thinking about reasons for living or staying alive -.25 -.18 .01 20. Thinking about good memories -.04 -.09 .21 21. Thinking about things in the future looking forward to -.09 .02 .11 22. Being around friends .04 -.14 .14 23. Being around people .01 .01 .19 24. Making meaning out of the situation -.09 .16 .22 25. Engaging in a positive activity (eg., hobby, games, etc) .02 .02 .27 26. Playing music (e.g., guitar, piano) .12 .11 .08 27. Anticipate othersâ reactions if you were to act on your suicidal thoughts -.02 .13 .22 28. Thinking about others with similar problems -.01 -.19 -.05 29. Going on social media (e.g., Instagram, Snapchat, etc) -.08 .01 .17 30. Thinking about how painful or scary it would be -.17 -.03 .03 31. Using an app on your phone designed for coping .01 .07 .09 32. Taking a psychiatric medication -.13 .05 .07 33. Taking a hot bath or shower -.09 -.05 .04 34. Cooking -.01 .03 -.04 35. Remove means that could be used from home or reducing ease of access -.001 .16 .23 36. Going to sleep/taking a nap .20 .05 .20 Note. Current SI (suicidal ideation) measured using the first 7 items of the Beck Scale for Suicide ideation; worst-point SI measured using an item from the self-injurious thoughts and behaviors interview (see methods section); SA = suicide attempt. Correlations > .25 have p values <.01; correlations .20 - .24 have p values <.05; correlations <.20 have p values > .05. For ease of presentation, correlations > |.20| are bolded. aPoint-biserial correlations reported given that history of suicide attempts is a dichotomous variable 71 Finally, correlations between suicide-related variables (current suicidal ideation, worst-point ideation and attempt history) and SSC dimensions (Adaptive and Maladaptive Frequency scales, Adaptive and Maladaptive Variety scales, Knowledge/Confidence) were examined. Results are reported in Table 9. Correlations ranged from negligible to moderate in strength (|rs| = .01 - .32). Small to moderate associations were observed between current suicidal ideation and Maladaptive Variety scale (r = .24, p = .01) and Knowledge/Confidence (r = -.32, p = .003). A moderate association was also found between worst point ideation and Maladaptive Frequency scale (r = .30, p = .002). Small to moderate associations were found between history of suicide attempt and Adaptive Frequency (r = .29, p = .005) and Adaptive Variety (r = .25, p = .02) scales. Table 9 Study 1 Research Question 3: Correlations between dimensions of suicide specific coping and current suicidal ideation, worst-point ideation, and suicide attempt history Suicide-specific coping variables Current SI Worst-point SI SA historya Adaptive Frequency scale -.01 .04 .29 Maladaptive Frequency scale .17 .30 .15 Adaptive Variety scale .10 .08 .25 Maladaptive Variety scale .24 .12 .10 Knowledge/Confidence -.32 .01 .14 Note. Current SI (suicidal ideation) measured using the first 7 items of Beck Scale for Suicide ideation; worst-point SI measured using an item from the self-injurious thoughts and behaviors interview (see methods section); Knowledge/Confidence measured using the Suicide-Related Coping Scale (Stanley et al., 2017); SA = suicide attempt. Suicide-specific coping scales are created from summing adaptive and maladaptive items from interview administered items (see Appendix A). Adaptive and Maladaptive scale items differ from items used for scales in Study 2. Correlations > .25 have p values < .01; correlations .20 - .24 have p values <.05; correlations < .20 have p values > .05. For ease of presentation, correlations > |.20| are bolded. aPoint-biserial correlations reported given that history of suicide attempts is a dichotomous variable. 72 Robustness Checks Research findings can be highly sensitive to data analytic decisions, leading to meaningfully different conclusions in some cases (Olsson-Collentine et al., 2023). Robustness checks are thus important for determining stability across reasonable analytic choices; greater stability of findings across reasonable analytic decisions indicates greater robustness of findings, while discrepancies suggest fragility (Klonsky, 2025; Nuijten, 2022; Olsson-Collentine et al., 2023; Steegen et al., 2016). Including robustness checks can thus help to guard against potential researcher degrees of freedom. This section reports on a robustness check regarding a change made to the data analytic plan following the original conception of the dissertation. The original data analytic plan stated that the full score of the Beck Scale for Suicide Ideation (BSS) would be used to capture suicidal ideation. However, as outlined in the methods section, the full BSS measure captures aspects of suicidal thoughts and behaviour other than suicidal ideation (e.g., plans, preparations). As such, to more accurately capture suicidal ideation (the construct of interest in this dissertation), factor analysis was used to identify and sum items measuring suicidal ideation only. This decision to only include items capturing suicidal ideation follows best practice suggestions for measuring suicidal ideation in research (Christensen & Victor, in press), and resulted in a 7-item measure for analyses. However, as a robustness check and in the spirit of transparency, key analyses are reported using the total scale version of the BSS as originally proposed and are reported below. In Study 1, results from correlational analyses between the BSS and SSC dimensions were highly similar to results reported in main results section using the 7-item version of the BSS. Suicidal ideation had minimal to small correlations with SSC dimensions of Adaptive Frequency (total BSS r = .003; 7-item BSS r = -.01), Maladaptive Frequency (total BSS r = .15; 73 7-item BSS r = .17), Adaptive Variety (total BSS r = .11; 7-item BSS r = .10), and Maladaptive Variety (total BSS r = .18; 7-item BSS r = .24), and moderate negative correlations with Knowledge/Confidence (total BSS r = -.31; 7-item BSS r = -.32). Together, these analyses suggest that Study 1 findings appear robust across different ways of measuring suicidal ideation. 74 Study 2 Study 2 Methods Procedure Study 2 used a longitudinal design and included 400 adults with past week suicidal ideation recruited via the online platform Prolific (Palan & Schitter, 2018). Prolific has been used previously to examine clinical populations using a longitudinal design (Stanton et al., 2022), including research on suicidal ideation (Chang et al., 2022; Sewall et al., 2021). Previous research suggests that longitudinal research conducted through Prolific has similar, if not better, retention rates compared with undergraduate samples, that internal reliability of measures collected through Prolific were of similar quality or better compared to undergraduate samples, and that test-retest reliability through Prolific conforms with theoretical expectations of measures (Stanton et al., 2022). In sum, Prolific offers an effective and efficient platform for online data collection. For this study, potential participants were pre-screened in two phases. First, participants who indicated on the general Prolific pre-screen questionnaire that they were 19 years or older, located in Canada or the United States, fluent in English, had a 95% approval rating or greater on Prolific, and who had completed at least 25 submissions on Prolific (as recommended by Prolific for longitudinal research) were eligible to complete a custom pre-screening questionnaire for the present study. This brief pre-screen survey included one question about frequency of suicidal thoughts in the past week embedded among four questions that asked about symptoms of depression and general anxiety (Kroenke et al., 2009; Löwe et al., 2010). Adults who indicated that they had thought about suicide at least once in the past week were eligible to sign up to 75 participate in the current study. To increase the likelihood that participants would be experiencing ongoing suicidal ideation over the two weeks of study participation, a time window of participation for this study was set such that potential participants were only eligible to participate in the study within one day of completing the pre-screen questionnaire. Participants were restricted to those living in North America in order to provide them with appropriate mental health resources and crisis resources at the end of each survey. Participants were compensated at Prolificâs recommended hourly wage for each time point. Participants who signed up for the present study were first provided with information about the study, including the longitudinal nature and time commitment: one 30-minute online survey at baseline, and one 20-minute online survey to be completed one week later. The period of one week between study time points was chosen in order to examine the longitudinal relationship between SSC and suicidal ideation over a shorter timeframe compared to previous research (e.g., Interian et al., 2021), while also capturing more lasting impacts of SSC on ideation compared to more immediate, potentially temporary impacts of SSC. Past research using a one-week longitudinal design has also demonstrated that both suicidal ideation and general coping responses fluctuate over this weekly time period (Selby et al., 2013; Stanley et al., 2021; Thompson et al., 2025), suggesting this is a relevant and important timeframe for examining the relationship between SSC and suicidal ideation. Finally, past research using Prolific for a two-week longitudinal design in a sample screened in for mental health issues (i.e., self-reported history of any mental health disorder diagnosis, and drinking alcohol at least one weekly on average) found that retention over the two-week time period was high (88%; Stanton et al., 2022). Thus this was determined to be a suitable timeframe for the present study. 76 At time 1, participants provided informed consent, and completed measures assessing: demographic information, suicidal ideation, SSC responses, general coping, emotion regulation, distress tolerance, psychological pain, connectedness, history of suicide attempts, and variables not analyzed for the purposes of the present study (experiences of emotion, borderline personality disorder traits, hopelessness, and meaningfulness in life). Following time 1, participants were contacted one week later using their unique de-identified user code to be invited to complete the briefer, time 2 survey. Participants were asked to provide their unique Prolific ID code at time 2 in order to anonymously link data across time points. Time 2 variables were the same as time 1, with the following variables not included: demographic information, history of suicide attempts, and the experiences of emotion measure. At the end of the survey at each time point, participants were provided with wellness resources, including information regarding crisis services. Participants were compensated upon completing each time point for their participation. This study received ethics approval through UBC. Participants Demographic characteristics of the sample for Study 2 are reported below in Table 10. The mean age of participants was 35.70 (range = 19 â 71, median = 34), just over half of participants identified their gender as men (54%), more than half of participants reported a straight sexual orientation (67%), and regarding ethnicity and racial background, more than half of participants reported being White/European (67%). 77 Table 10 Study 2 demographic characteristics Mean (SD) Range Age 35.70 (11.18) 19 â 71 n % Gender Woman 163 41% Man 214 54% Fluid, Nonbinary 21 5% Prefer not to answer 2 0.5% English is Primary Language Yes 363 91% No 36 9% Racial and Ethnic Background Black 31 8% East Asian Descent 28 7% Indian-South Asian Descent 7 2% Indigenous 3 1% Latin American-Hispanic Descent 27 7% Middle Eastern Descent 4 1% Mixed race/ethnicity 18 4.5% Southeast Asian 10 3% White/European Descent 267 67% Other 1 0.25% Prefer not to answer 2 0.5% Sexual Orientation Straight (Heterosexual) 266 67% Asexual/Aromantic 12 3% Bisexual 68 17% Gay 18 4.5% Lesbian 10 2.5% Pansexual 17 4% Questioning 7 2% Other 2 0.5% Marital status Single 232 58% Dating/in a relationship 20 5% Married/Common-law 119 30% Divorced/Separated 22 5.5% Widowed 7 2% Working Yes 299 75% No 101 25% Hours Working per Week 1 â 9 hours 9 2% 10 â 19 hours 22 5.5% 20 â 29 hours 34 8.5% 30 â 39 hours 60 15% 78 40 â 49 hours 160 40% 50 â 59 hours 19 5% 60 â 69 hours 3 1% > 80 hours 1 0.3% Highest level education Some high school 3 1% High school graduate/GED 54 13.5% Some college or university 115 29% Bachelorâs degree 176 44% Some graduate or professional school 9 2% Masterâs degree 34 8.5% Doctoral degree 9 2% Yearly household income (before tax) < $5,000 19 5% $5,000 - $9,999 9 2% $10,000 - $19,999 39 10% $20,000 - $29,999 34 8.5% $30,000 - $39,999 27 7% $40,000 - $49,999 31 8% $50,000 - $59,999 43 11% $60,000 - $74,999 46 12% $75,000 - $99,999 64 16% $100,000 - $499,999 81 20% > $500,000 1 0.3% Prefer not to answer 6 1.5% Note. Sample size for demographic information ranges from 398 â 400 due to missing data for some items; see results section for full details of missing data. Measures Below, descriptions of all measures in the study are provided. Main study variables are described first, followed by covariates. Coping with Suicidal Ideation Self-Report Measure. The Frequency and Variety dimensions of SSC were assessed using a 32-item self-report measure developed for this study (see Appendix B for measure). The development of this measure was informed by the semi-structured interview of SSC used in Study 1. As described previously, the Study 1 interview assessed 36 different SSC responses, including those suggested by suicide prevention websites, social media platforms, 79 reported in the scientific literature on individuals at risk for suicide, and included in empirically supported treatments for suicide risk. To create this 32-item measure for Study 2, eight items were dropped from the original 36 items in the interview due to low endorsement and redundancy (see Appendix C), and four new items were added upon further consulting the literature on additional coping responses to suicidal ideation. The items added were: fantasizing about dying/suicide (Marchionatti et al., 2024; Shneidman, 1996); eating disordered behaviours including purging, restricting, and binging (Joiner et al., 2022; Shahnaz & Klonsky, 2021); ignoring or supressing suicidal ideation (Pettit et al., 2009); and engaging in risky behaviours (Ammerman et al., 2018; Nock et al., 2018). See Appendix C for details regarding items included in the 32-item measure, including the dropped items and new items. This 32-item self-report measure instructed participants to respond to each SSC item using a 5-point Likert scale ranging from 1 (âNeverâ) to 5 (âAlwaysâ) to indicate the frequency with which they used the response to cope with suicidal ideation in the past week. This measure was administered at both time points and used to capture the Frequency and Variety dimensions of SSC. A shortened version of this scale was piloted on 6 participants from Study 1 who were recently suicidal (i.e., suicidal in the past week). One suggestion was to edit instructions to clarify that participants report on âactual coping responses usedâ, as opposed to what a participant might âtypically do in a hypothetical situationâ. As such, for each coping item, participants were also asked to report their best estimation of the exact number of times they used the coping item over the past week. Quantifying Dimensions of SSC. Responses to this measure were used to assess two dimensions of SSC: Frequency and Variety. Scoring procedures for this measure were similar to procedures used in Study 1 to score Frequency and Variety dimensions. 80 To quantify Frequency and Variety of SSC, items were first classified as adaptive or maladaptive. Following procedures described in Study 1, expert clinical judgment was used to code the 32 items in this self-report measure as adaptive or maladaptive (see Appendix B for classification of items). Frequency was quantified in two ways: first by examining frequency of individual items, and second by summing frequency scores for all adaptive responses (Adaptive Frequency scale), and summing frequency scores for all maladaptive responses (Maladaptive Frequency scale). Variety was quantified based on the overall number of adaptive responses and maladaptive responses used, regardless of frequency of use. All SSC items were recoded as a 1 (âUsed at least oneâ) or a 0 (âNever usedâ) based on whether a participant reported ever using the item over the past week. Specifically, all SSC items with a score of 2 (âRarelyâ) or higher on the 5-point Likert frequency scale were coded as a 1. All SSC items with a score of 1 (âNeverâ) were coded as a 0. Scores for adaptive responses were summed (Adaptive Variety scale), and scores for maladaptive responses summed (Maladaptive Variety scale) to reflect the overall the number of different adaptive and maladaptive SSC responses an individual used over the past week. Suicide-Related Coping Scale (SRCS; Stanley et al., 2017). The Suicide-Related Coping Scale (SRCS; Stanely et al., 2017) is a 17-item self-report measure which assesses the Knowledge/Confidence dimension of SSC (see Appendix D). The SRCS does not specify a timeframe, thus instructions for this study were modified to ask about SSC during the past week (the time period of interest in this study). The SRCS is composed of items capturing external methods of coping with suicidal ideation (e.g., I know which friends and/or family members to contact to help take my mind off my suicidal feelings; I know it is important to limit access to weapons or other ways to hurt myself when I am feeling suicidal) and internal methods of coping 81 with suicidal ideation (e.g., I can distract myself by doing other things or thinking about other things when I am feeling suicidal; if one way of trying to cope with suicidal feelings does not work, I have other ways to try). The total score for the SRCS has demonstrated good internal reliability in previous research (Cronbachâs alpha = .89; Stanley et al., 2017), and given the previously described discrepancies in factor structure across research (Stanley et al., 2017; Rainbow et al., 2023), the present study used the total score of the SRCS. The SRCS was administered at both time points. Suicidal Ideation. Past week suicidal ideation was measured using the Beck Scale for Suicide Ideation (BSS; Beck & Steer, 1991) at each time point. The BSS consists of 19 items that assess suicidal ideation and risk. Instructions for the BSS were modified to ask participants to report on suicidal ideation experienced over the past week. Previous factor-analytic work finds evidence that certain items from the BSS assess experiences distinct from the construct of suicidal ideation, including preparations, plans, and courage for suicide (Beck et al., 1979; 1997; Dhingra et al., 2018). Research aims of this dissertation focused on suicidal ideation specifically, and thus only items assessing ideation were selected for analyses (as recommended by best practices on measuring suicidal ideation; see Christensen & Victor, in press). This was accomplished by conducting EFA (with promax rotation) at each time point to identify the items that load to the suicidal ideation factor. EFA factor loadings and eigenvalues are reported below in Table 11. At time 1, the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was adequate (KMO = .91), Bartlettâs test of sphericity significant (p < .001), and Determinant appropriate (Determinant = .001), suggesting acceptability for conducting EFA. Examining the scree plot and eigenvalues suggested that a two or three-factor solution was appropriate. Requiring each 82 factor to have a minimum of three unique loadings found that only the two-factor solution met this requirement (only item 11 loaded strongly to factor 3 in the three-factor solution). Factor 1 explained 34% of variance (eigenvalue = 6.47) and included 7 items that represented suicidal ideation that loaded above .40 and did not have substantial cross-loadings (items: 1 â 7; see Table 11). Similar to time 1, analyses at time 2 suggested acceptability for conducting EFA (KMO = .91, Bartlettâs test of sphericity significant: p < .001; Determinant = .001). Examining the scree plot and eigenvalues suggested a two or three-factor solution. Requiring each factor to have a minimum of three unique loadings found that only the two-factor solution met this requirement. As such, consistent with time 1, the two-factor solution was chosen. Factor 1 explained 36% of variance (eigenvalue = 6.80) and included 7 items (items: 1 â 7) that represented suicidal ideation. Factor loadings at time 1 and 2 were highly similar (see Table 11). Based on these results, the first seven items of the BSS were identified as capturing suicidal ideation, and these items were summed for a score of suicidal ideation intensity. These results are consistent with previous factor analysis findings (Dhingra et al., 2018). As with Study 1, the decision to only include items capturing suicidal ideation was made during data analyses. This decision was made after further reflection on what the total score of BSS represents, and importance of utilizing clear measurement of suicidal ideation, not conflated with other constructs (e.g., preparations, plans, reasons for suicide, etc.; Christensen & Victor, in press). However, we recognize the potential threat of post-hoc researcher degrees of freedom. Therefore, as a robustness check, we also report results from key analyses using the full BSS score at the end of the results section. 83 Table 11 Factor Loadings from Exploratory Factor Analysis (EFA) of Beck Scale for Suicide ideation (BSS) in Study 2 at time 1 (n = 390) and time 2 (n = 330) Time 1 Time 2 Item Factor 1 Factor 2 Factor 1 Factor 2 1. Wish to live .85 -.30 .86 -.36 2. Wish to die .78 -.18 .66 -.11 3. Reasons to die outweigh reasons to live .78 -.13 .85 -.17 4. Desire to kill myself .66 -.03 .58 .10 5. Taking steps to avoid death in life-threatening situation .68 -.02 .76 -.12 6. How long do thoughts of killing myself last .61 .12 .65 .06 7. How often think about killing myself .56 .14 .60 .09 8. Accept the idea of killing myself .50 .20 .57 .15 9. Able to keep myself from committing suicide .41 .28 .38 .38 10. Concern about consequences of unsuccessful attempt .32 .28 .53 .09 11. Reasons for attempting suicide .20 -.24 .22 -.42 12. Plan for suicide .19 .45 .15 .50 13. Access and opportunity to use method -.04 .46 .13 .35 14. Courage and ability to commit suicide .06 .54 .22 .40 15. Sure I will make a suicide attempt .35 .46 .41 .43 16. Preparations for suicide .04 .71 .03 .73 17. Suicide note -.11 .64 -.05 .63 18. Arrangements for after Iâve committed suicide -.02 .59 .04 .53 19. Hidden desire to kill myself from others .05 -.12 .10 -.16 Eigenvalues 6.47 1.74 6.80 1.71 % of variance 34% 9% 36% 9% Note. Bolded loadings indicate items that load >.40, have no notable cross-loadings, and consistently load to Factor 1 at time 1 and time 2. Items that load to Factor 1 (1 â 7) are summed to create the Suicidal Ideation variable for both Study 1 and 2. Sample sizes at time 1 and 2 consist of participants who had nonzero score on the first 5 items and thus completed all 19 items of the BSS. In addition to the BSS, four questions from the SITBI (Nock et al., 2007) were used to assess characteristics of suicidal ideation. Items included those on lifetime history of suicidal ideation, age at first time of suicidal ideation, the number of times suicidal ideation was experienced in the past week, and lifetime worst point intensity of suicidal ideation (rated on a 5-point Likert scale, ranging from 0 = âlow/littleâ to 4 = âvery much/severeâ). General Coping. To assess past week general coping, this study included the Brief COPE (Carver, 1997; Heffer & Willoughby, 2017) at each time point. Instructions do not specify a timeframe, thus for the present study, a timeframe of past week was specified to ensure 84 participants reported on the same timeframe as other key variables (e.g., SSC, suicidal ideation). The Brief COPE is one of the most frequently used measures of general coping (Kato, 2015), and importantly, is the measure used by the few longitudinal studies which have assessed general coping and future suicidal ideation (Heffer & Willoughby, 2017; Horwitz et al., 2018). This measure consists of 28 items which form 14 subscales of lower order coping responses, each composed of 2 items. A recent systematic review of the factor structure of the Brief COPE found that a range of 2 â 15 factors are identified in the literature for the Brief COPE, however, a 2-factor solution is the most frequently identified factor solution (Solberg et al., 2022). This commonly identified 2-factor solution reflects higher-order factors of Adaptive and Maladaptive coping (these factors have also been labelled as âApproachâ and âAvoidanceâ in the literature). EFA with Promax rotation was conducted to determine whether the two-factor solution was found in the present sample (see Table 12 below for results). Preliminary analyses suggested acceptability for conducting EFA at time 1. The KMO measure of sampling adequacy was adequate (KMO = .80) and Bartlettâs test of sphericity significant (p < .001). However, the low determinant value suggested multicollinearity (Determinant = .000001). Item level correlations were examined to identify and remove strong correlations (r > .75), resulting in two items removed: item 4 (substance use) and item 10 (informational support). Running the EFA with those items removed resulted in a similarly appropriate KMO value (KMO = .83), significant Bartlettâs test of sphericity (p <.001), and Determinant above the suggested cut-off (Determinant = .000017; Field, 2013). The scree plot and eigenvalues suggested that a two or three factor solution was appropriate. Examining items for the two-factor solution appeared to reflect the Adaptive, or Approach (Factor 1) and Maladaptive, or Avoidant (Factor 2) factor solutions found previously in the literature (Solberg et al., 2022). In examining the three-factor solution, the 85 second factor appeared to be only composed of three items capturing informational and emotional support and correlated strongly with Factor 1 (r =.57). As such, the two-factor solution was chosen. Upon examining item content of these factors (see Table 12), they are henceforth referred to as Approach (Factor 1) and Avoidance (Factor 2), as these labels more accurately reflect the item content and also help to distinguish the item content in these factors compared with the Adaptive and Maladaptive SSC scales (these differences are addressed further in the discussion section). Items with loadings greater than .40 were included in the total factor scores, and weak loadings and cross-loadings not included. Factor 1 explained 25% of variance (eigenvalue = 6.40) and included 12 items that were considered to capture Approach coping (Solberg et al., 2022). Factor 2 explained 11% of variance (eigenvalue = 2.83) and included 4 items that were considered to capture Avoidance coping (Solberg et al., 2022). This approach was repeated at time 2. Similar to time 1, preliminary analyses suggested acceptability for conducting EFA. The KMO measure of sampling adequacy was adequate (KMO = .82) and Bartlettâs test of sphericity significant (p < .001). Similar to time 1, the low determinant suggested multicollinearity (Determinant = .0000007). Item correlations were examined to identify and remove strong correlations (r > .75), resulting in four items removed: item 4 (substance use), item 10 (informational support), item 15 (emotional support) and item 22 (religion). Conducting the EFA with those items removed resulted in a similarly appropriate KMO value (KMO = .81), significant Bartlettâs test of sphericity (p <.001), and Determinant above the suggested cut-off (Determinant = .00009; Field, 2013). Similar to time 1, a two-factor solution was appropriate. Items with loadings greater than .40 were included in the total factor scores, and weak loadings and cross-loadings not included. Factor 1 (Approach) explained 23% 86 of variance (eigenvalue = 5.65) and consisted of 9 items. Factor 2 (Avoidance) explained 12% of variance (eigenvalue = 2.93) and consisted of 4 items. Items that loaded to factors at both of the time points were summed create the subscales to represent Approach general coping (COPE â Approach; items: 2, 5, 7, 12, 14, 17, 23, 25, 27) and Avoidant general coping (COPE â Avoid; items: 3, 6, 8, 16) for covariate analyses. 87 Table 12 Factor Loadings for Exploratory Factor Analysis (EFA) of Brief COPE at time 1 (n=394) and time 2 (n=376) Time 1 Time 2 Item Factor 1 Factor 2 Factor 1 Factor 2 1. Self-distraction (I've been turning to work or other activities to take my mind off things) .41 -.03 .34 .01 2. Active coping (I've been concentrating my efforts on doing something about the situation I'm in) .61 -.04 .64 -.09 3. Denial (I've been saying to myself "this isn't real.") .24 .56 .24 .46 4. Substance use (I've been using addictive behaviors or substances to make myself feel better) -a -a -a -a 5. Emotional support (I've been getting emotional support from others) .60 -.15 .59 -.03 6. Behavioral disengagement (I've been giving up trying to deal with it) -.26 .64 -.29 .65 7. Active coping (I've been taking action to try to make the situation better) .70 -.16 .76 -.14 8. Denial (I've been refusing to believe that it has happened) .25 .60 .19 .57 9. Venting (I've been saying things to let my unpleasant feelings escape) .46 .34 .42 .38 10. Informational support (Iâve been getting help and advice from other people) .69 .34 -a -a 11. Substance use (I've been using alcohol or other drugs to help me get through it) .06 .31 .10 .30 12. Positive reframing (I've been trying to see it in a different light, to make it seem more positive) .70 -.09 .73 -.01 13. Self-blame (Iâve been criticizing myself) -.12 .35 -.11 .34 14. Planning (I've been trying to come up with a strategy about what to do) .55 .05 .63 -.01 15. Emotional support (I've been getting comfort and understanding from someone) .64 -.07 -a -a 16. Behavioral disengagement (I've been giving up the attempt to cope) -.16 .67 -.34 .64 17. Positive reframing (I've been looking for something good in what is happening) .74 -.08 .74 -.06 18. Humor (I've been making jokes about it) .36 .23 .37 .38 19. Self-distraction (I've been doing something to think about it less, such as going to moviesâ¦etc) .33 -.02 .22 .05 20. Acceptance (I've been accepting the reality of the fact that it has happened) .34 .03 .33 .09 21. Venting (I've been expressing my negative feelings) .32 .25 .34 .29 22. Religion (I've been trying to find comfort in my religion or spiritual beliefs) .43 .16 -a -a 23. Informational support (Iâve been trying to get advice/help from other people about what to do) .66 -.001 .63 .04 24. Acceptance (I've been learning to live with it) .24 -.03 .39 .03 25. Planning (I've been thinking hard about what steps to take) .63 .02 .61 -.02 26. Self-blame (Iâve been blaming myself for things that happened) -.09 .34 -.07 .36 27. Religion (I've been praying or meditating) .40 .09 .40 .13 28. Humor (I've been making fun of the situation) -a -a .33 .40 Eigenvalues 6.40 2.83 5.64 2.95 % of variance 25% 11% 23% 12% Note. Bolded loadings indicate items that load >.40, have no notable cross-loadings, and consistently loaded to each factor at time 1 and time 2 Bolded items summed to create scores for Approach and Avoidance COPE variables used in covariate analyses for study 2. aIndicates item removed due to multicollinearity (inter-item correlations r = >.75). 88 Distress Tolerance. To assess past week distress tolerance, this study used the Distress Tolerance Scale (DTS; Simons & Gaher, 2005). The DTS is a 15-item self-report measure which assesses the perceived capacity to tolerate negative emotions. Participants rated items using a 5-point Likert scale ranging from 1 (âStrongly Disagree) to 5 (âStrongly Agreeâ) with higher scores reflecting less ability to tolerate distress. Instructions do not specify a timeframe, and thus consistent with the approach taken for other measures, a timeframe of past week was specified to ensure participants reported on the same timeframe as other study variables. This measure has demonstrated good internal reliability (Cronbachâs a range: .87 - .89; Interian et al., 2018; Rainbow et al., 2023) and validity in past research (Interian et al., 2018; Simons & Gaher, 2005). This measure was administered at both time points and used as a covariate in analyses. Emotion Regulation. To assess past week emotion regulation, this study used the brief version of the Difficulties in Emotion Regulation Scale (DERS-18; Victor & Klonsky, 2016). The DERS-18 is composed of 18 items which participants responded to using a 5-point Likert scale ranging from 1 (âAlmost Neverâ; 0-10%) to 5 (âAlmost Alwaysâ; 91-100%), with higher scores indicating greater difficulties with emotion regulation. Instructions do not specify a timeframe, and thus a timeframe of past week was specified to ensure consistency in timeframe across study variables. The DERS-18 has been examined in psychiatric, community, and university samples, demonstrating good internal reliability (Cronbachâs a range: .87 - .92), concurrent validity with the full DERS, and convergent validity with symptoms of BPD (Victor & Klonsky, 2016). In the present study this measure was administered at both time points and used as a covariate in analyses. Psychological Pain. Past week psychological pain was assessed in the present study using the Unbearable Psychache Scale (UP3; Pachkowski et al., 2019), a shortened version of the 89 Psychache Scale (Holden et al., 2001). The UP3 is composed of 3 items which specifically measure unbearable psychological pain, the type of psychological pain suggested to be most relevant to suicidal ideation (Pachkowski et al., 2019; Shneidman, 1993). Participants responded to items indicating the extent to which they have experienced the pain described in each item using a 5-point Likert scale ranging from 1 (âStrongly disagreeâ) to 5 (âStrongly agreeâ). Items are summed with scores ranging from 3 â 15, and higher scores indicate greater pain. Instructions do not specify a timeframe, thus for the present study, a timeframe of past week was specified to be consistent with other study measures. The UP3 has been examined in online and clinical samples, demonstrating good internal reliability (Cronbachâs a = .93) and strong correlations with related variables (Pachkowski et al., 2019). The UP3 was administered at both time points and used as a covariate in analyses examining 3ST variables. Connectedness. To assess the 3ST variable connectedness over the past week, this study used a subscale from the Interpersonal Needs Questionnaire (INQ-10; Bryan, 2011; Van Orden et al., 2008). The INQ-10 is a shortened, 10-item version of the original 25-item INQ scale. The INQ-10 has two subscales, which capture perceived burdensomeness and thwarted belongingness. The thwarted belongingness subscale (INQ-TB) used in the present study assessed the extent to which one feels a lack of connection to others. This subscale is composed of 5 items, and are rated on a 7-point Likert scale ranging from 1 (ânot at all true for meâ) to 7 (âvery true for meâ). Items were reverse scored and summed, with higher scores representing greater belongingness (i.e., more connection). This subscale has demonstrated good internal reliability in previous research (Cronbachâs a range: .86 â .88; Bryan, 2011; Pachkowski et al., 2019). The INQ-TB scale was administered at both time points and used as a covariate in analyses examining 3ST variables. 90 Pain minus Connectedness Differential. The 3ST postulates that suicidal ideation increases when the amount of pain one is experiencing exceeds or overwhelms their level of connectedness. To capture this, the present study computed a pain minus connectedness differential score in accordance with methods used by previous studies examining 3ST variables (Klonsky & May, 2015; Klonsky et al., 2021). To do this, first the UP3 and INQ-TB scores were standardized. Next, INQ-TB scores were subtracted from UP3 scores. The resulting scores reflect the relative experience of pain compared to connectedness for participants. This variable was used as a covariate in analyses examining 3ST variables. Data Quality Assurance. To ensure data quality, one validity question was placed at the start of time 1 to ensure only participants meeting study inclusion criteria regarding suicidal ideation (i.e., presence of suicidal ideation in past week) completed the study. This was the same item administered in the pre-screen survey to assess for presence of suicidal ideation over the past week. In addition, four attention checking questions were placed throughout the survey at each time point (e.g., please answer âstrongly agreeâ). Participants who failed more than one of the four attention checking questions contained throughout the survey were excluded from analyses. Similar methods of ensuring data quality have been used by previous longitudinal research conducted through Prolific (Stanton et al., 2022). Demographics. A standard demographics form developed by the laboratory was used to collect information on age, gender, language, ethnicity and race, sexual orientation, income, education, employment, and history of psychiatric treatment. This form was administered at time 1 only. Suicide History. Suicide history was assessed using a measure comprised of 6 items drawn from standardized measures of suicide history. Specifically, 4 items from the YRBS 91 (Brener et al., 2002; Kolbe et al., 1993) were used to assess lifetime history and recent (past 12-month) history of suicide plans and suicide attempt. Two items from the SASII (Linehan et al., 2006) assessed the medical severity of lifetime history and recent (past 12-month) suicide attempts. These items have demonstrated good reliability and validity in previous research. These questions were included at time 1 only and provided information regarding the clinical characteristics of the sample. Data Analytic Plan Data Preparation and Preliminary Analyses. Data were examined to identify and remove participants who failed to respond to the first validity question appropriately and who failed more than one of the four attention checking questions in the survey. Time 2 responses were linked with time 1 using Prolific IDs. Attrition was examined to determine whether attrition in this study was as expected based on previous research in similar samples (Chang et al., 2022; Stanton et al., 2022). Past research with Prolific using a two-week time window and a clinical sample found 88% retention (Stanton et al., 2022), and in a study examining suicidal ideation 79% retention for a one-month follow up (Chang et al., 2022). Descriptive statistics were examined to determine normality of study variables and internal reliability of measures. Correlations between all key variables and test-retest correlations were examined. Changes from time 1 to time 2 in key variables were also examined. Correlational analyses and t tests explored differences in SSC across demographic characteristics and treatment history. Although not a central research aim of Study 2, the frequency of individual SSC items was also reported to mirror Study 1 analyses. 92 Study 2 Research Questions. Study 2 had three overarching research questions: (1) What is the relationship between SSC and suicidal ideation? (2) Are different dimensions of SSC uniquely related to suicidal ideation beyond their association with general coping? (3) Is the relationship between SSC and suicidal ideation explained by variables emphasized in the 3ST? The original data analytic plan for Study 2 proposed examining the longitudinal relationship between variables using multiple regression and partial correlations. However, it was later determined that a cross-lagged panel model (CLPM) would best characterize the bidirectional relationships between SSC and suicidal ideation, measured at two time points (Orth et al., 2021). This approach characterizes both contemporaneous and longitudinal relationships. CLPM is also particularly well-positioned to estimate longitudinal relationships, because unlike other analytic methods, CLPM accounts for variable stability across time-points and concurrent and reciprocal associations when estimating the longitudinal direction of effects. For this study, CLPM allowed for the examination of whether past week SSC predicted changes in next week suicidal ideation, and vice versa. Given the small number of studies which have examined SSC, and the absence of research examining the bidirectional relationship between SSC and suicidal ideation, this study was primarily exploratory. Full results are presented with this in mind and provided to the field as a basis for hypothesis and idea generation. Effect-sizes are reported to indicate magnitude of effect, and p values are reported as a continuous indicator of an effect sizeâs reliability (Greenland et al., 2016). Effect sizes yielded by CLPM analyses are interpreted following recently proposed guidelines for interpreting the size of cross-lagged effects (Orth et al., 2024): small (.03), medium (.07), and large (.12). This study was pre-registered with Open Science Framework (OSF) on August 1, 2023: https://doi.org/10.17605/OSF.IO/PBH97. 93 Power Analysis As described above, upon further reflection the decision to utilize CLPM for key analyses in Study 2 was made. Thus power was calculated given the sample size collected. Power was calculated for possible cross-lagged effects in CLPMs examining SSC and suicidal ideation, for covariate analyses (which included a third variable in the CLPM), and for multiple groups CLPM to explore differences which emerged in SSC across demographic and clinical characteristics. The semPower package for cross-lagged panel models in R was used for power calculations (Moshagen & Bader, 2023). Based on effect size guidelines for cross-lagged effects (Orth et al., 2024), the current study with a (longitudinal) sample of 350 was estimated to have 87% power to detect large cross-lagged effects (.12), 40% power to detect medium cross-lagged effects (.07), and 11% power to detect small effects (.03). This suggested that the study had appropriate power to detect large effects and was likely underpowered to detect medium-sized and smaller effects. Power for covariate analyses was estimated based on recommendations from Kline (2015) of an N:q ratio of 10 â 20 participants per parameter; for a CLPM including three variables at each time point (i.e., CLPM with the inclusion of one covariate), a sample of 270 - 540 would be needed, and thus the present sample of 350 participants for longitudinal analyses was deemed to be reasonably powered. Given the possibility of differences in SSC emerging across demographic and clinical subgroups, power was also calculated conducted using semPower for these possible multiple group CLPM analyses. These calculations found that for subgroup comparisons, power was estimated to be <40%. Although these multiple group analyses were still conducted for exploratory purposes, results should be interpreted with caution given they are underpowered. 94 Study 2 Results Preliminary Considerations As noted previously, due to the significant gap of empirical literature on SSC, this dissertation takes an exploratory approach (Althouse, 2016; Streiner, 2015). Similar to Study 1, Study 2 is guided largely by research questions and hypotheses were reserved for cross-sectional correlations between dimensions of SSC and suicidal ideation. Given the large number of analyses conducted across individual items and scales, it is important to recognize the increased probability of finding effects that are poor estimates of true population parameters. Although applying strict significance thresholds and corrections for multiple comparisons is common when conducting many analyses, this approach is often not suitable for exploratory data analysis (Althouse, 2016; Streiner, 2015). Instead, I report full analyses and results to enable proper interpretation, facilitate future confirmatory studies, and maximize the utility of these findings for future meta-analyses (Greenland et al., 2016; Wasserstein & Lazar, 2016). In addition, readers should interpret results cautiously, keeping in mind the higher probability that some results inevitably will be poor estimates of population parameters. To support accurate and thoughtful interpretation of results, I steer away from âsignificantâ versus ânot significantâ terminology, and instead focus on effect sizes as information about magnitude of an effect and p values as a dimensional indicator of the reliability of an effect (Althouse, 2016; McShane et al., 2019). 95 Data Preparation This study was composed of three parts: a brief pre-screen survey, time 1 (completed on the same day as the pre-screen), and time 2 (completed one week following time 1). A total of 37,811 active participants on Prolific were eligible to complete the pre-screen survey as determined by the following criteria: located in Canada or the United States, fluent in English, 19 years or older, previous approval rating on Prolific >95%, and completed at least 25 previous Prolific studies. A total of 3,450 participants completed the pre-screen survey between August 9 â August 30, 2023; median pre-screen completion time was 41 seconds. An additional 38 participants began the survey but chose not to submit survey results, and 14 participants timed-out after taking more than 13 minutes to complete the survey. Of the 3,450 participants that completed the pre-screen, 593 (17%) endorsed past week suicidal ideation, 2,855 (83%) denied past week suicidal ideation, and 2 participants (<1%) did not answer the item in the pre-screen about past week suicidal ideation. All eligible participants (those who endorsed past week suicidal ideation) were invited to participate in time 1. At time 1, a total of 415 participants (out of 593 invited) submitted survey responses for Time 1 questionnaires. After removing duplicate responses (n=12) and participants that failed to pass the suicidal ideation validation item (n=3), 400 participants remained at time 1. Among these 400 participants, 3 failed more than one of the four attention checking questions and were excluded from analyses. Among these 397 participants, 4 participants had missing data on some items (approximately 1% missing data). This resulted in a sample of 393-394 (depending on if a participant had missing data for that measure) for time 1 analyses. All time 1 participants were invited to complete time 2. 96 Longitudinal analyses were conducted with participants who had passed attention checking questions at each time point and who had completed time 2 within 7-10 days following time 1. This resulted in 312 â 350 participants (approximately 78-88% of original sample) for longitudinal analyses. These details regarding time 2 participation are described below. Of the 400 original participants who had completed time 1, 382 completed time 2 (approximately 95% retention), an attrition rate comparable to previous research using similar timeframes (Chang et al., 2022; Stanton et al., 2022). No participants failed to accurately provide their Prolific ID at time 2, and thus all participants at time 2 were linked with their time 1 data. The mean number of days between time 1 and time 2 was 7.68 (SD=3.21) and the median number of days was 6.93. Of the 382 participants who completed time 2, 318 participants (83%) completed time 2 seven days after time 1, as planned. The remaining participants completed time 2 eight days after time 1 (n=21; 5%), nine days after time 1 (n=12; 3%), 10 days after time 1 (n=7; 2%), 11 â 14 days after time 1 (n=15; 4%), and the remaining 15 - 42 days after time 1 (n=9; 2%). Given that key research aims of this study were to examine the longitudinal relationship between variables one week apart, main analyses were conducted with participants who completed time 2 between 7 â 10 days following time 1 (n=358). Five participants failed more than one of the four attention checking questions at time 2 and were excluded from analyses. At time 2, 39 participants denied any suicidal thoughts in the past week, and thus did not complete the two SSC measures for the past week (i.e., coping with suicidal ideation self-report measure and SRCS) and only provided valid data on measures that did not require presence of suicidal ideation in the past week to complete (i.e., BSS and covariate measures). This resulted in a total of 314 participants for time 2 analyses on SSC, and 353 participants for 97 time 2 analyses excluding time 2 SSC. After excluding participants who failed attention check requirements at time 1, this resulted in 312 â 350 participants for longitudinal analyses. Preliminary Analyses Clinical characteristics of Study 2. Clinical characteristics of the sample are reported below in Table 13. At time 1, all participants reported having experienced suicidal ideation in the past week: 74% reported ideation on less than half of the days in the past week, and the remaining 26% reported ideation on more than half the days in the prior week. At time 2 (one week later), 25% reported no suicidal ideation in the past week, 57% reported suicidal ideation on less than half of the days in the past week, and the remaining 18% reported experiencing suicidal ideation on more than half the days in the prior week. Nearly three-quarters of the sample had made a plan for suicide at some point in their lifetime (70%) and just under half had made a suicide attempt at some point in their lifetime (42%). 98 Table 13 Study 2 clinical characteristics Variable n % Ever received mental health treatment Yes 282 71% No 117 29% Number of visits for mental health 0 visits 117 29% 1 â 9 visits 58 14.5% 10 â 49 visits 83 21% 50 â 99 visits 46 11.5% 100 â 499 visits 67 17% 500 â 999 visits 23 6% > 1,000 visits 5 1% Mean (SD) Range Suicidal Ideation Age of first-time SI 17.18 (7.98) 3 â 58 Worst point SI (lifetime) 3.13 (0.99) 0 â 4 n % Frequency past week suicidal ideation (time 1) No days 0 0% Several days 295 74% More than half the days 63 16% Nearly every day 42 10% Frequency past week suicidal ideation (time 2) No days 94 25% Several days 220 57% More than half the days 41 11% Nearly every day 27 7% Lifetime history of plan for suicide Yes 279 70% No 120 30% Lifetime history suicide attempt Yes 167 42% No 233 58% Suicide attempt required medical treatment Yes 89 53% No 78 47% Plan for suicide (past 12 months) Yes 185 46% No 215 54% Suicide attempt (past 12 months) Yes 77 19% No 323 81% Suicide attempt (past 12 months) required medical treatment Yes 33 43% No 44 57% Note. SI=suicidal ideation. Sample size ranges n= 399-400 at time 1 due to missing data on some items; sample size n= 382 at time 2 due to attrition; see data preparation section for full details. 99 Normality of data and psychometrics. Descriptive statistics and internal reliability for all variables are reported in Table 14. All variables were normally distributed (Skewness and Kurtosis < |2|). Variables demonstrated good internal reliability at each time point. An exception to this was the Maladaptive Frequency and Variety scales, which had relatively lower internal reliability (Cronbachâs as = .58 - .68). Given the potential formative nature of maladaptive coping, this was not determined to be a limiting factor for using this variable in analyses. Correlations between all key variables (and test-retest correlations) are reported in Table 15. All SSC variables exhibited cross-sectional associations with one another at each time point, ranging from small to large. There were positive associations between Frequency scales (i.e., Adaptive and Maladaptive; rs = .22, .31; time 1 and 2 respectively) and Variety scales (i.e., Adaptive and Maladaptive; rs = .27, .53; time 1 and 2 respectively). Knowledge/Confidence was positively associated with other Adaptive scales (rs = .31 - .42) and negatively associated with Maladaptive scales (rs = -.13 - -.30). The magnitude of these associations suggests that scales measured separate dimensions of SSC, with the exception of scales created from summing the same original items (e.g., Adaptive Frequency and Variety, Maladaptive Frequency and Variety; rs = .85 -.92). Test-retest correlations were strong for all variables, ranging from .63 - .84. Small to medium changes were observed from time 1 to time 2 in nearly all variables (ds = |0.13 â 0.53|); exceptions for which only minimal change was observed were: Knowledge/Confidence in SSC (d=0.03, p=.58), Adaptive General Coping (d =0.05, p=.36), Distress tolerance (d=0.06, p=.25), and the Pain â Connectedness differential (d=0.03, p=.28). Changes were largely in a similar direction, with scores for each variable decreasing from time 1 to time 2. The only exception was connectedness, which had a small increase from time 1 to time 2. When examining individual SSC items, most exhibited little, if any change (ds < 0.20). 100 Exceptions were decreases over time in: Socializing with friends/family and not mentioning suicidal thoughts (d=0.21, p<.001), Fantasizing about dying (d=0.42, p<.001), Thinking of others with similar problems (d=0.31, p<.001), Thinking about reasons for living (d=0.40, p<.001), Anticipating othersâ reactions if you were to act on suicidal thoughts (d=0.36, p<.001), and Withdrawing from others (d=0.24, p<.001). 101 Table 14 Descriptive statistics for Study 2 key variables at time 1 and time 2 Time 1 (ns = 393 â 394) Time 2 (ns = 314 â 353) Mean (SD) Range Skew Kurtosis a Mean (SD) Range Skew Kurtosis a Suicidal Ideation 5.96 (3.30) 0â14 0.39 -0.60 .85 4.74 (3.51) 0â14 0.52 -0.42 .85 Adaptive Frequency scale 36.43 (10.44) 19â76 1.19 1.70 .84 34.12 (11.20) 19â74 1.23 1.56 .88 Maladaptive Frequency scale 12.83 (3.89) 6â27 0.71 0.56 .58 11.88 (4.21) 6â26 0.77 0.42 .66 Adaptive Variety scale 7.91 (4.04) 0â19 0.85 0.61 .84 7.06 (4.60) 0â19 0.85 0.33 .88 Maladaptive Variety scale 2.89 (1.41) 0â6 0.48 -0.09 .58 2.55 (1.61) 0â6 0.50 -0.34 .68 Knowledge/Confidence 55.66 (12.99) 19â85 -0.36 -0.03 .88 54.44 (13.28) 19â83 -0.23 -0.37 .89 General Coping â Approach 18.42 (5.75) 9â35 0.38 -0.38 .85 18.21 (5.98) 9â36 0.41 -0.51 .87 General Coping â Avoidance 7.44 (2.73) 4â16 0.77 0.30 .73 7.23 (2.75) 4â16 0.61 -0.37 .72 Distress tolerance 49.38 (13.83) 15â75 -0.32 -0.38 .94 48.65 (14.26) 15â75 -0.29 -0.54 .94 Emotion Dysregulation 50.55 (12.89) 18â86 -0.07 -0.40 .88 49.00 (13.64) 18â84 0.01 -0.49 .90 Unbearable Psychache 9.43 (3.31) 3â15 -0.24 -0.80 .91 8.91 (3.36) 3â15 -0.01 -0.94 .92 Connectedness 13.71 (7.07) 5â35 0.52 -0.70 .89 14.96 (7.71) 5â35 0.37 -0.91 .90 Pain â Connectedness 0.01 (1.65) -4.94â2.92 -0.25 -0.56 - -0.01 (1.69) -4.42â3.12 -0.20 -0.77 - Note. Suicidal ideation measured with first 7 items of the Beck Scale for Suicide Ideation. Suicide-specific coping (SSC) variables are Adaptive and Maladaptive Frequency, Adaptive and Maladaptive Variety, and Knowledge/Confidence. SSC scales created from summing adaptive and maladaptive items from SSC self-report measure (see Appendix B). SSC Adaptive and Maladaptive items differ from items used for SSC variables in Study 1. Knowledge/Confidence in SSC measured using the Suicide-Related Coping Scale (Stanley et al., 2017). Pain â Connectedness variable created by subtracting standardized Unbearable Psychache scores from standardized Connectedness scores, and thus there are no individual scale items with which to calculate Cronbachâs a. Sample size ranges due to missing data on some items; details reported in data preparation section. 102 Table 15 Correlations between Study 2 variables at time 1 (upper triangle), time 2 (lower triangle), and test-retest (diagonal) 1 2 3 4 5 6 7 8 9 10 11 12 13 1. Suicidal Ideation (.74) -.17 .45 -.13 .27 -.52 -.19 .43 .28 .29 .59 -.39 .59 2. Adaptive Frequency scale -.03 (.80) .22 .91 .41 .42 .56 .17 .05 .10 .01 .37 -.23 3. Maladaptive Frequency scale .46 .31 (.73) .27 .85 -.29 -.02 .39 .30 .42 .43 -.24 .40 4. Adaptive Variety scale -.02 .92 .35 (.79) .51 .34 .51 .18 .09 .12 .05 .36 -.19 5. Maladaptive Variety scale .35 .43 .89 .53 (.70) -.13 .10 .36 .24 .38 .32 -.07 .23 6. Knowledge/Confidence -.47 .39 -.30 .31 -.19 (.84) .54 -.31 -.25 -.30 -.41 .53 -.57 7. General Coping â Approach -.24 .57 -.03 .53 .06 .51 (.75) .02 -.04 -.09 -.10 .43 -.32 8. General Coping â Avoidance .45 .14 .37 .17 .38 -.34 -.06 (.63) .30 .40 .51 -.12 .38 9. Distress tolerance .27 .06 .27 .10 .26 -.22 -.09 .36 (.80) .61 .49 -.27 .46 10. Emotion Dysregulation .32 .05 .38 .09 .35 -.31 -.16 .44 .65 (.82) .47 -.29 .46 11. Unbearable Psychache .62 -.002 .47 .07 .43 -.46 -.24 .54 .50 .49 (.70) -.35 .82 12. Connectedness -.38 .38 -.18 .35 -.06 .50 .49 -.21 -.29 -.33 -.41 (.78) -.83 13. Pain â Connectedness .60 -.23 .40 -.17 .30 -.58 -.44 .44 .47 .49 .84 -.84 (.75) Note. Correlations in parentheses are test-retest correlations from time 1 and 2. Cross-sectional correlations at time 1 are reported in the upper triangle, and cross-sectional correlations at time 2 are reported in the lower triangle. All time 1 correlations > .17 have ps <.001; correlations .14 - .17 have ps <.01; correlations .11 - .13 have ps< .05; correlations < .11 have ps > .05. All time 2 correlations > .18 have ps <.001; correlations .14 â 18 have ps <.01; correlations .11 - .13 have ps <.05; correlations < .11 have ps >.05. Test retest correlations ns = 312â 350; time 1 analyses ns = 349 - 350; time 2 analyses ns = 312 â 350. Suicidal ideation measured using the first 7 items of the Beck Scale for Suicide ideation. Knowledge/Confidence in suicide-specific coping measured using Suicide-Related Coping Scale (Stanley et al., 2017). Suicide-specific coping (SSC) variables: Adaptive and Maladaptive Frequency, Adaptive and Maladaptive Variety, and Knowledge/Confidence. SSC scales created from summing adaptive and maladaptive items from SSC self-report measure (see Appendix B). SSC Adaptive and Maladaptive items differ from items used for SSC variables in Study 1. 103 Differences Across Participant Characteristics. Differences in SSC dimensions across demographic variables and psychiatric treatment history were examined. To increase statistical power, multiple categories within a demographic variable were collapsed. For example, for sexual orientation, categories of asexual, bisexual, gay, lesbian, pansexual, questioning, and other were collapsed into a ânot straightâ category to allow for a comparison of âstraightâ and ânot straightâ sexual orientations. Although this decision maximizes size of subgroups for analyses, it ignores differences between each of these identifies, including for other demographic variables assessed, and are limitations of these analyses. No meaningful differences emerged across age, gender, or ethnicity/race. Differences were observed across sexual orientation, with participants who reported a non-straight sexual orientation (e.g., queer, bisexual, gay) reporting greater scores on Maladaptive Frequency (d=0.28, p=.01) and Maladaptive Variety (d=0.24, p=.04) scales compared with participants who reported a straight sexual orientation. Differences were observed across relationship status, with participants who were currently in a relationship reporting greater scores on Knowledge/Confidence (d=0.40, p<.001), Adaptive Frequency (d=0.34, p=.008), and Adaptive Variety (d=0.30, p=.02) scales compared with participants who were not in a relationship. Differences were observed across level of education, with participants who reported attaining a Bachelorâs degree or higher reporting greater scores on Knowledge/Confidence (d=0.23, p=.02), Adaptive Frequency (d=0.35, p<.001), and Adaptive Variety (d=0.42, p<.001) scales compared with participants who reported not having attained a Bachelorâs degree or higher. Differences were observed across annual household income, with participants who reported earning an annual household income greater than $60,000 reporting greater scores on Knowledge/Confidence (d=0.29, p=.005) and the Adaptive Frequency (d=0.22, p=.04) scale 104 compared with participants who reported earning less than $60,000. Differences also emerged across psychiatric history, with participants who reported a history of at least some mental health treatment reporting greater scores on Knowledge/Confidence (d=0.45, p<.001), Adaptive Frequency (d=0.26, p=.02), and Adaptive Variety (d=0.29, p=.009) scales, and greater scores on the Maladaptive Variety (d=0.22, p=.05) scale. Frequency of SSC Items in Study 2. Means (and SDs) and percentages of frequency for each SSC item administered in Study 2 are reported below in Table 16 for both time 1 and 2.105 Table 16 Study 2 frequency of suicide-specific coping items used in the past week Suicide-specific coping item Time 1 (n=394) Time 2 (n=314) Mean (SD) % used often Mean (SD) % used often Withdraw from others and stay alone 3.38 (1.41) 53% 3.15 (1.54) 49% Distract by keeping busy 3.30 (1.24) 48% 3.03 (1.40) 42% Positive activity 3.12 (1.28) 42% 2.91 (1.36) 38% Fantasize about dying 2.89 (1.09) 27% 2.52 (1.15) 19% Think of reasons for living 2.89 (1.33) 31% 2.37 (1.30) 21% Socialize, do not mention suicidal thoughts 2.67 (1.31) 30% 2.38 (1.24) 19% Ignore/suppress suicidal thoughts 2.65 (1.36) 29% 2.49 (1.44) 27% Think about othersâ reactions if acted on suicidal thoughts 2.62 (1.47) 30% 2.15 (1.35) 18% Use social media 2.38 (1.47) 26% 2.19 (1.39) 23% Think of good memories 2.29 (1.18) 15% 2.11 (1.20) 14% Sleep/nap 2.25 (1.35) 21% 2.09 (1.26) 17% Think about how painful/scary acting on SI would be 2.19 (1.39) 22% 1.99 (1.26) 15% Use substances (e.g., alcohol, non-prescription drugs) 2.08 (1.38) 20% 1.96 (1.38) 18% Think about things looking forward to 2.05 (1.20) 14% 1.83 (1.10) 9% Think of others with similar problems 2.02 (1.13) 11% 1.74 (1.05) 9% Find positive meaning or âsilver liningâ 1.86 (1.13) 10% 1.71 (1.08) 9% Eating disordered behaviors (binging, purging, restriction) 1.74 (1.16) 11% 1.63 (1.09) 9% Exercise/recreational physical activity 1.74 (1.17) 12% 1.67 (1.11) 10% Warm bath/shower 1.69 (1.12) 9% 1.6 (1.01) 7% Listen to sad music/watch a sad movie 1.65 (1.07) 8% 1.59 (1.03) 8% Socialize, mention suicidal thoughts 1.64 (1.01) 8% 1.74 (1.06) 10% Meditation or mindfulness 1.59 (0.98) 6% 1.6 (1.04) 7% Go to a public place (e.g,. coffee shop, park) 1.58 (1.01) 8% 1.5 (0.95) 6% Turn to religion/spirituality 1.54 (1.07) 8% 1.46 (1.00) 7% Engage in self-harm without intending to die 1.42 (0.87) 6% 1.34 (0.75) 3% Talk with a therapist/health professional 1.37 (0.88) 6% 1.29 (0.82) 4% Engage in risk taking behaviors 1.33 (0.83) 4% 1.29 (0.78) 4% Use strong sensations for grounding (e.g., cold temperature) 1.29 (0.76) 3% 1.25 (0.72) 3% Remove means/reduce ease of access to means for suicide 1.24 (0.78) 4% 1.25 (0.73) 4% Contact crisis center 1.18 (0.59) 2% 1.19 (0.64) 3% Go to hospital 1.13 (0.50) 1% 1.13 (0.54) 2% Use a Safety Plan 1.13 (0.52) 2% 1.15 (0.57) 3% Note. Items ordered from most to least frequently used according to time 1 mean. Frequency ratings range from 1 (âneverâ) to 5 (âalwaysâ). Percentage of participants âused oftenâ computed by summing proportion of participants who reported using item âusuallyâ or âalwaysâ. Item content shortened for brevity; full item content reported in Appendix B. SI = suicidal ideation. See data preparation section for full details on sample size at each time point.106 Interpreting CLPM Results. CLPM was used in Study 2 to examine the reciprocal relationship between SSC and suicidal ideation across two waves of data. CLPM was conducted using Mplus Version 8.11 (Muthén & Muthén, 1998). Because the CLPMs for this study were saturated (i.e., had zero degrees of freedom), model fit could not be assessed. CLPM provides four key pieces of information. First, information regarding the stability of variables over time was estimated by autoregressive paths, and reported below as standardized beta coefficients. Larger autoregressive effects suggest greater variable stability across time. Second, and of most interest for this study, information was provided regarding the extent to which one variable (e.g., SSC) predicted change in another variable (e.g., suicidal ideation) over time, while controlling for the stability of each variable from one time point to the next (i.e., autoregressive path). This was estimated by the cross-lagged paths, and reported below as standardized beta coefficients. Interpretation of these cross-lagged effects followed recent guidelines for small (.03), medium (.07), and large (.12) effects (Orth et al., 2024). Third, CLPM accounted for the concurrent association between variables at time 1, which was reported as correlation coefficients. Fourth, CLPM also estimated the relationship between unexplained variance of variables at time 2, which was reported in figures as the standardized residual covariance. Research Question 1 (Study 2): Relationship between SSC and Suicidal Ideation Research question 1 examined the relationship between SSC and suicidal ideation. The first way this was examined was by conducting CLPMs for each dimension of SSC (i.e., Adaptive Frequency, Maladaptive Frequency, Adaptive Variety, Maladaptive Variety, and Knowledge/Confidence). Following this, multiple groups CLPMs were conducted to follow-up on subgroup differences observed previously (i.e., differences across participant characteristics). 107 Finally, CLPMs were conducted to examine each individual SSC response. See Appendix F for 95% confidence intervals for these main analyses. CLPM examining SSC dimensions. Full results for CLPM analyses examining each SSC dimension are reported in Table 17. Overall, at time 1 there were cross-sectional associations between suicidal ideation and all SSC dimensions: small negative associations with Adaptive Frequency (r = -.17, p < .001) and Adaptive Variety (r = -.13, p < .01), small to medium positive associations with Maladaptive Frequency (r = .45, p < .001) and Maladaptive Variety (r =.27, p <.001), and a large negative association with Knowledge/Confidence (r = -.52, p < .001). In most CLPMs, cross-lagged effects were small (Ãs â¤ .07) and generally less statistically reliable (ps > .05). Exceptions to this were CLPMs examining Maladaptive Frequency and Knowledge/Confidence dimensions. Table 17 CLPM results for all dimensions of suicide-specific coping and suicidal ideation Suicide-specific dimension in CLPM SSC2 on SSC1 (autoregressive effect) SI2 on SI1 (autoregressive effect) SI2 on SSC1 (cross-lagged effect) SSC2 on SI1 (cross-lagged effect) SSC1 with SI1 (correlation) SSC2 with SI2 (residual covariance) Frequency of Adaptive .81 (<.001) .75 (<.001) .05 (.14) .06 (.09) -.17 (.001) -.01 (.92) Frequency of Maladaptive .70 (<.001) .70 (<.001) .09 (.03) .06 (.13) .45 (<.001) .36 (<.001) Variety of Adaptive .79 (<.001) .75 (<.001) .06 (.11) .04 (.23) -.13 (.01) -.01 (.93) Variety of Maladaptive .69 (<.001) .72 (<.001) .07 (.05) .05 (.22) .27 (<.001) .31 (<.001) Knowledge/Confidence .82 (<.001) .68 (<.001) -.12 (.003) -.03 (.35) -.52 (<.001) -.24 (<.001) Note. SSC = suicide-specific coping dimension; SI = suicidal ideation (measured using first 7 items of the Beck Scale for Suicidal ideation). Knowledge/Confidence in SSC measured using Suicide-Related Coping Scale (Stanley et al., 2017). Subscripts 1 and 2 denote time points 1 and 2. Standardized effects are reported, with p values reported in parentheses (see Appendix F for 95% confidence intervals). Sample size for analyses n=312. 108 CLPM examining Maladaptive Frequency and Suicidal Ideation. As shown in Figure 1 below, there was a moderate positive cross-lagged effect of Maladaptive Frequency scale at time 1 predicting suicidal ideation at time 2 (Ã = .09, p = .03). Autoregressive paths were large for Maladaptive Frequency scale (Ã = .70, p < .001) and for suicidal ideation (Ã = .70, p < .001). There was a small positive cross-lagged effect of suicidal ideation at time 1 predicting Maladaptive Frequency scale at time 2, however this effect was less statistically reliable (Ã = .06, p =.13). Figure 1 CLPM for Frequency of Maladaptive suicide-specific coping and suicidal ideation Note. FreqM = Maladaptive Frequency scale of suicide-specific coping; SI = suicidal ideation (measured by first 7 items of Beck Scale for Suicide ideation). Subscripts indicate time point. Standardized estimates are shown, with standard errors reported in parentheses. 109 CLPM examining Knowledge/Confidence and Suicidal Ideation. As shown in Figure 2 below, there was a large negative cross-lagged effect of Knowledge/Confidence in SSC at time 1 predicting suicidal ideation at time 2 (Ã = -.12, p = .003). Autoregressive paths were large for Knowledge/Confidence (Ã = .82, p < .001) and for suicidal ideation (Ã = .68, p < .001). The cross-lagged effect of suicidal ideation at time 1 did not appear to predict Knowledge/Confidence at time 2 (Ã = -.03, p =.35). Figure 2 CLPM for Knowledge/Confidence in suicide-specific coping and suicidal ideation Note. SRCS = Knowledge/Confidence in suicide-specific coping (measured with Suicide-Related Coping Scale); SI = suicidal ideation (measured with first 7 items of Beck Scale for Suicide ideation). Subscripts indicate time point. Standardized estimates are shown, with standard errors reported in parentheses. CLPM exploring subgroup differences. As reported in preliminary analyses, differences were observed in SSC dimensions across the following participant characteristics: sexual orientation, relationship status, highest level of education, annual household income, and 110 psychiatric treatment history. Multiple groups CLPMs were conducted to further explore these differences in the relationship between SSC and suicidal ideation. However, because power calculations suggested that these analyses were substantially underpowered (<40% power), these analyses should be interpreted with caution. As such, full results from multiple groups CLPMs are reported in Appendix E, and overall trends summarized here. Potential differences emerged across sexual orientation, highest level education, and household income. Those with a straight sexual orientation appeared to have a larger positive cross-lagged effect of Maladaptive Frequency and Variety scales at time 1 predicting suicidal ideation at time 2 (compared to those with a non-straight sexual orientation), those with a Bachelorâs degree or higher appeared to have a larger positive cross-lagged effect of Adaptive Frequency and Variety at time 1 predicting suicidal ideation at time 2 (compared to those who had not attained a Bachelorâs degree), and those with an annual household income greater than $60,000 appeared to have a larger positive cross-lagged effect of Adaptive Frequency at time 1 predicting suicidal ideation at time 2 (compared to those with an annual income less than $60,000). CLPM examining individual SSC items. Next, CLPMs were conducted to assess the reciprocal relationship between each individual SSC item and suicidal ideation. Full results for all items are reported below in Table 18. Cross-lagged effects predicting future suicidal ideation. Four SSC items at time 1 were observed to have cross-lagged effects predicting suicidal ideation at time 2: Risk-taking behaviors, Fantasizing about dying, Positive activity, and Means safety. There was a large positive cross-lagged effect of Risk-taking behaviors at time 1 predicting suicidal ideation at time 2 (Ã = .13, p < .001). Autoregressive paths were moderate to 111 large for Risk-taking behaviors (Ã = .48, p < .001) and for suicidal ideation (Ã = .72, p < .001). There was a medium positive (though less statistically reliable) cross-lagged path of suicidal ideation at time 1 predicting Risk-taking behaviors at time 2 (Ã = .08, p =.12). There was a small positive cross-sectional correlation observed between Risk-taking behavior and suicidal ideation at time 1 (r = .19, p <.001). There was a moderate positive cross-lagged effect of Fantasizing about dying at time 1 predicting suicidal ideation at time 2 (Ã = .10, p = .01). There was also a large positive cross-lagged effect of suicidal ideation at time 1 predicting Fantasizing about dying at time 2 (Ã = .23, p < .001). Autoregressive paths were moderate to large for Fantasizing about dying (Ã = .45, p < .001) and for suicidal ideation (Ã = .69, p < .001). There was a strong positive cross-sectional correlation observed between Fantasizing about dying at time 1 and suicidal ideation at time 1 (r =.52, p <.001). There was a moderate positive cross-lagged effect of Positive activity at time 1 predicting suicidal ideation at time 2 (Ã = .09, p = .01). Autoregressive paths were moderate to large for Positive activity (Ã = .49, p < .001) and for suicidal ideation (Ã = .76, p < .001). There was a moderate positive (though less statistically reliable) cross-lagged path of suicidal ideation at time 1 predicting Positive activity at time 2 (Ã = .07, p =.15). Interestingly, there was a small negative cross-sectional correlation observed between Positive activity and suicidal ideation at time 1 (r = -.21, p <.001). There was also a moderate positive cross-lagged effect of Means safety at time 1 predicting suicidal ideation at time 2 (Ã = .07, p = .05). Autoregressive paths were moderate to large for Means safety (Ã = .52, p < .001) and for suicidal ideation (Ã = .74, p < .001). The cross-lagged path of suicidal ideation at time 1 did not appear to predict Means safety at time 2 (Ã 112 = .03, p =.60). There was a negligible cross-sectional correlation observed between Means safety and suicidal ideation at time 1 (r = .04 p =.41). Cross-lagged effects predicting future SSC. Examining cross-lagged effects revealed that suicidal ideation at time 1 predicted five SSC responses at time 2: Fantasizing about dying, Eating disorder-related behaviors, Ignoring or suppressing suicidal thoughts, Thinking of reasons for living, and Contacting a crisis center. Among these items, Fantasizing about dying was the only item (and SSC variable) to exhibit a bidirectional relationship with suicidal ideation. As reported above, there was a large positive cross-lagged effect of suicidal ideation at time 1 predicting Fantasizing about dying at time 2 (Ã = .23, p < .001), and moderate positive cross-lagged effect of Fantasizing about dying at time 1 predicting suicidal ideation at time 2 (Ã = .10, p = .01). Autoregressive paths were moderate to large for Fantasizing about dying (Ã = .45, p < .001) and suicidal ideation (Ã = .69, p < .001), and there was a strong positive cross-sectional correlation observed between Fantasizing about dying and suicidal ideation at time 1 (r = .52, p <.001). There was a large positive cross-lagged effect of suicidal ideation at time 1 predicting Eating disorder-related behaviors at time 2 (Ã = .13, p = .004). The autoregressive paths were large for Eating disorder-related behaviors (Ã = .63, p < .001) and suicidal ideation (Ã = .74, p < .001). The cross-lagged path of Eating disorder-related behaviors at time 1 did not appear to predict suicidal ideation at time 2 (Ã = .04, p =.27). There was a small positive cross-sectional correlation observed between Eating disordered-related behaviors and suicidal ideation at time 1 (r = .16, p =.002). There was a large negative cross-lagged effect of suicidal ideation at time 1 predicting Ignoring or suppressing suicidal thoughts at time 2 (Ã = -.12, p = .02). The autoregressive paths 113 were moderate to large for Ignoring or suppressing suicidal thoughts (Ã = .45, p < .001) and suicidal ideation (Ã = .76, p < .001). The cross-lagged path of Ignoring or suppressing suicidal thoughts at time 1 did not appear to predict suicidal ideation at time 2 (Ã = .05, p =.17). There was a medium negative cross-sectional correlation between Ignoring or suppressing suicidal thoughts and suicidal ideation at time 1 (r = -.28, p < .001). There was a moderate negative cross-lagged effect of suicidal ideation at time 1 predicting Thinking of reasons for living at time 2 (Ã = -.11, p = .03). The autoregressive paths were moderate to large for Thinking of reasons for living (Ã = .48, p < .001) and suicidal ideation (Ã = .72, p < .001). There was a small negative (and less statistically reliable) cross-lagged effect of Thinking of reasons for living at time 1 predicting suicidal ideation at time 2 (Ã = -.06, p =.12). There was a medium sized negative cross-sectional correlation between Thinking of reasons for living and suicidal ideation at time 1 (r = -.32, p < .001). Finally, there was a moderate positive cross-lagged effect of suicidal ideation at time 1 predicting Contacting a crisis center at time 2 (Ã = .09, p = .04). The autoregressive paths were large for Contacting a crisis center (Ã = .60, p < .001) and suicidal ideation (Ã = .74, p < .001). The cross-lagged path of Contacting a crisis center at time 1 did not appear to predict suicidal ideation at time 2 (Ã = .03, p = .46). Interestingly, no cross-sectional correlation was observed between Contacting a crisis center and suicidal ideation at time 1 (r = .07, p = .22). No additional longitudinal relationships were observed between SSC items and suicidal ideation in CLPMs. Full results are reported in Table 18 below. 114 Table 18 CLPM results for individual suicide-specific coping items and suicidal ideation SSC item specified in CLPM SSC2 on SSC1 (autoregressive effect) SI2 on SI1 (autoregressive effect) SI2 on SSC1 (cross-lagged effect) SSC2 on SI1 (cross-lagged effect) SSC1 with SI1 (correlation) SSC2 with SI2 (residual covariance) 1. Socialize, mention SI .61 (<.001) .74 (<.001) .02 (.65) -.01 (.89) .05 (.36) -.10 (.13) 2. Socialize, do not mention SI .54 (<.001) .74 (<.001) -.01 (.87) .02 (.70) -.14 (.006) .01 (.91) 3. Fantasize about dying .45 (<.001) .69 (<.001) .10 (.01) .23 (<.001) .52 (<.001) .40 (<.001) 4. Contact crisis center .60 (<.001) .74 (<.001) .03 (.46) .09 (.04) .07 (.22) -.02 (.79) 5. Think of good memories .63 (<.001) .75 (<.001) .02 (.65) -.01 (.77) -.25 (<.001) -.11 (.07) 6. Use substances .70 (<.001) .74 (<.001) .02 (.59) .03 (.45) .11 (.03) .17 (.01) 7. Think of others with similar problems .43 (<.001) .74 (<.001) -.004 (.91) -.01 (.88) -.08 (.12) .03 (.64) 8. Distract by keeping busy .52 (<.001) .74 (<.001) .01 (.69) -.02 (.64) -.13 (.01) .04 (.55) 9. Positive activity .49 (<.001) .76 (<.001) .09 (.01) .07 (.15) -.21 (<.001) -.13 (.03) 10. NSSI .58 (<.001) .75 (<.001) -.03 (.40) .04 (.35) .26 (<.001) .26 (<.001) 11. Think of reasons for living .48 (<.001) .72 (<.001) -.06 (.12) -.11 (.03) -.32 (<.001) .02 (.71) 12. Go to public place .58 (<.001) .74 (<.001) .02 (.56) -.001 (.99) -.03 (.53) .10 (.09) 13. Think of how others would react if acted on SI .47 (<.001) .74 (<.001) .001 (.98) -.05 (.36) -.11 (.04) .10 (.11) 14. Meditation or mindfulness .49 (<.001) .75 (<.001) .03 (.35) -.01 (.86) -.11 (.04) .003 (.96) 15. Eating behaviours (binging, purging, restriction) .63 (<.001) .74 (<.001) .04 (.27) .13 (.004) .16 (.002) .12 (.05) 16. Withdraw from others .63 (<.001) .73 (<.001) .03 (.35) .05 (.24) .32 (<.001) .27 (<.001) 17. Think about things looking forward to .50 (<.001) .75 (<.001) .02 (.65) -.01 (.79) -.29 (<.001) -.15 (.02) 18. Sleep/nap .58 (<.001) .74 (<.001) .05 (.19) .03 (.54) .10 (.06) -.03 (.54) 19. Warm bath/shower .61 (<.001) .74 (<.001) .03 (.32) .05 (.29) .07 (.17) .06 (.32) 20. Religion/spirituality .72 (<.001) .74 (<.001) .04 (.27) .05 (.22) -.05 (.35) .08 (.17) 21. Means safety .52 (<.001) .74 (<.001) .07 (.05) .03 (.60) .04 (.41) .11 (.07) 22. Find positive meaning .49 (<.001) .74 (<.001) .003 (.92) -.07 (.15) -.23 (<.001) .01 (.84) 23. Social media .63 (<.001) .74 (<.001) .01 (.68) .02 (.60) .08 (.13) .04 (.49) 24. Sad music/movie .55 (<.001) .74 (<.001) .03 (.40) .05 (.33) .23 (<.001) .13 (.04) 25. Think of how painful/scary acting on SI would be .56 (<.001) .74 (<.001) .04 (.29) .05 (.30) -.03 (.57) .05 (.39) 26. Ignore/supress SI .45 (<.001) .76 (<.001) .05 (.17) -.12 (.02) -.28 (<.001) -.01 (.88) 27. Strong sensations for grounding .52 (<.001) .74 (<.001) .04 (.32) .02 (.65) .04 (.40) .16 (.01) 28. Risk taking behaviors .48 (<.001) .72 (<.001) .13 (<.001) .08 (.12) .19 (<.001) .03 (.67) 29. Therapist/health professional .68 (<.001) .74 (<.001) .06 (.11) .01 (.77) -.001 (.98) .03 (.61) 30. Exercise .72 (<.001) .74 (<.001) .06 (.10) .001 (.99) -.04 (.49) .09 (.15) 31. Go to hospital .80 (<.001) .74 (<.001) .04 (.26) -.06 (.08) .10 (.05) .04 (.54) 32. Use Safety Plan .68 (<.001) .74 (<.001) .05 (.13) .01 (.77) .02 (.77) .15 (.02) Note. SSC = suicide-specific coping; SI = suicidal ideation (measured using first 7 items of the Beck Scale for Suicidal ideation). Subscripts 1 and 2 denote time points 1 and 2. Standardized effects are reported, with p values reported in parentheses (see Appendix F for 95% confidence intervals). Sample size for analyses n=312. 115 Research Question 2 (Study 2): Coping-related Covariate Analyses The second research question examined whether SSC dimensions remained uniquely related to suicidal ideation when accounting for coping-related covariates including other SSC dimensions, and general coping, distress tolerance, and emotion regulation abilities. These covariates were added to the CLPMs for the two SSC dimensions observed to predict suicidal ideation in research question 1 analyses: Maladaptive Frequency and Knowledge/Confidence. CLPM controlling for other SSC dimensions. A CLPM was conducted that included Maladaptive Frequency, Knowledge/Confidence, and suicidal ideation. Results revealed that the cross-lagged paths for both the Maladaptive Frequency scale and Knowledge/Confidence remained. As shown in Figure 3, a large negative cross-lagged effect of Knowledge/Confidence in SSC at time 1 predicted suicidal ideation at time 2 (Ã = -.12, p = .005), and a medium positive cross-lagged effect of Maladaptive Frequency at time 1 predicted suicidal ideation at time 2 (Ã = .08, p = .04). Cross-lagged effects predicting SSC dimensions at time 2 were small and less statistically reliable (Ãs < |.06|, ps > .06). 116 Figure 3 CLPM of relationship between suicide-specific coping dimensions (Maladaptive Frequency and Knowledge/Confidence) and suicidal ideation Note. SRCS = Knowledge/Confidence in suicide-specific coping (measured with Suicide-Related Coping Scale); SI = suicidal ideation (measured with first 7 items of Beck Scale for Suicide ideation); FreqM = Maladaptive Frequency scale of suicide-specific coping. Subscripts indicate time point. Standardized estimates are shown, standard errors reported in parentheses. For ease of presentation, only pathways with medium-sized or larger cross-lagged effects are shown; see results for full details. CLPM controlling for general coping, distress, and emotion regulation. Next, I examined whether SSC dimensions at time 1 predicted suicidal ideation at time 2 controlling for general approach coping (COPE-Approach), general avoidance coping (COPE-Avoid), distress tolerance, and emotion regulation. Maladaptive Frequency Scale. Maladaptive Frequency scale at time 1 continued to predict suicidal ideation at time 2 when controlling for each covariate, with the exception of 117 emotion regulation. The CLPM including COPE-Approach as the covariate found a medium positive cross-lagged effect of Maladaptive Frequency at time 1 predicting suicidal ideation at time 2 (Ã = .09, p = .02). All other cross-lagged effects were small and less statistically reliable (Ãs < |.07|, ps > .08). A CLPM including COPE-Avoid as the covariate found similar results, with a medium positive cross-lagged effect of Maladaptive Frequency at time 1 predicting suicidal ideation at time 2 (Ã = .09, p = .02). There was also a large positive cross-lagged effect of suicidal ideation at time 1 predicting COPE-Avoid at time 2 (Ã = .13, p = .005). All other cross-lagged effects were less statistically reliable (Ãs < |.08|, ps > .06). A CLPM including distress tolerance as the covariate found similar results, with a medium positive cross-lagged effect of Maladaptive Frequency at time 1 predicting suicidal ideation at time 2 (Ã = .09, p = .02). There was also a medium positive cross-lagged effect of Maladaptive Frequency at time 1 predicting distress tolerance at time 2 (Ã = .07, p = .04). All other cross-lagged effects were minimal and less statistically reliable (Ãs < |.03|, ps > .18). The CLPM including emotion regulation as the covariate found that although there was a medium positive cross-lagged effect of Maladaptive Frequency at time 1 predicting suicidal ideation at time 2, it was less statistically reliable (Ã = .08, p = .07). All other cross-lagged effects were minimal (Ãs < |.03|, ps > .16). Knowledge/Confidence. Knowledge/Confidence of SSC at time 1 continued to predict suicidal ideation at time 2 when controlling for each covariate. The CLPM including COPE-Approach as the covariate found a large negative cross-lagged effect of Knowledge/Confidence at time 1 predicting suicidal ideation at time 2 (Ã = -.13, p = .009). There was also a medium positive cross-lagged effect of Knowledge/Confidence at time 1 predicting COPE-Approach at 118 time 2 (Ã = .11, p = .03). All other cross-lagged effects were minimal and less statistically reliable (Ãs < |.04|, ps > .19). A CLPM including COPE-Avoid as the covariate found similar results, with a large negative cross-lagged effect of Knowledge/Confidence at time 1 predicting suicidal ideation at time 2 (Ã = -.12, p = .003). Two additional cross-lagged effects were observed in the CLPM; a medium negative cross-lagged effect of Knowledge/Confidence at time 1 predicting COPE-Avoid at time 2 (Ã = -.11, p = .02) and a medium positive cross-lagged effect of suicidal ideation at time 1 predicting COPE-Avoid at time 2 (Ã = .11, p = .03). All other cross-lagged effects were minimal (Ãs < |.03|, ps > .41). A CLPM including distress tolerance as the covariate found similar results, with a large negative cross-lagged effect of Knowledge/Confidence at time 1 predicting suicidal ideation at time 2 (Ã = -.12, p = .003). All other cross-lagged effects were small and less statistically reliable (Ãs < |.06|, ps > .11). The CLPM including emotion regulation as the covariate found similar results, with a medium negative cross-lagged effect of Knowledge/Confidence at time 1 predicting suicidal ideation at time 2 (Ã = -.11, p = .006). There was also a medium negative cross-lagged effect of Knowledge/Confidence at time 1 predicting emotion dysregulation at time 2 (Ã = -.10, p = .005). All other cross-lagged effects were minimal and less statistically reliable (Ãs < |.04|, ps > .21). Research Question 3 (Study 2): Suicide Theory-informed Covariate Analyses The third research question examined whether each SSC dimension remained uniquely predictive of suicidal ideation when accounting for covariates informed by suicide theory. These covariates were pain, connectedness, and the pain â connectedness differential, variables 119 emphasized in the 3ST for their role in explaining the intensity of suicidal ideation (Klonsky et al., 2021). These covariates were added to the CLPMs for the two SSC dimensions observed to predict suicidal ideation at time 2: Maladaptive Frequency and Knowledge/Confidence. CLPM with Maladaptive Frequency Scale and 3ST covariates. Maladaptive Frequency at time 1 continued to predict suicidal ideation at time 2 when controlling for connectedness, but not the other 3ST informed covariates. The CLPM including connectedness as the covariate found a medium positive cross-lagged effect of Maladaptive Frequency at time 1 predicting suicidal ideation at time 2 (Ã = .09, p = .03). All other cross-lagged effects were less statistically reliable (Ãs < |.09|, ps > .10). Results from these analyses are reported below. In the CLPM including psychological pain as the covariate, the cross-lagged effect of Maladaptive Frequency at time 1 predicting suicidal ideation at time 2 was small and less statistically reliable (Ã = .06, p = .11). Interestingly, a bidirectional relationship was observed between psychological pain and suicidal ideation, with a large positive cross-lagged effect of psychological pain at time 1 predicting suicidal ideation at time 2 (Ã = .12, p = .009), and medium positive cross-lagged effect of suicidal ideation at time 1 predicting psychological pain at time 2 (Ã = .10, p = .04). There was also a large positive cross-lagged effect of Maladaptive Frequency at time 1 predicting psychological pain at time 2 (Ã = .14, p = .001). There was a moderate positive (though less statistically reliable) cross-lagged effect of psychological pain at time 1 predicting Maladaptive Frequency at time 2 (Ã = .09, p = .06), and a minimal cross-lagged effect of suicidal ideation at time 1 predicting Maladaptive Frequency at time 2 (Ã = .02, p = .75). Finally, although the CLPM including pain â connectedness as a covariate found a medium positive cross-lagged effect of Maladaptive Frequency at time 1 predicting suicidal 120 ideation at time 2, it was less statistically reliable (Ã = .07, p = .07). A medium positive cross-lagged effect of pain-connectedness at time 1 predicted suicidal ideation at time 2 (Ã = .09, p = .05). There was also a medium positive cross-lagged effect of Maladaptive Frequency at time 1 predicting pain â connectedness at time 2 (Ã = .08, p = .03). All other cross-lagged effects were minimal (Ãs < |.04|, ps > .34). CLPM with Knowledge/Confidence and 3ST covariates. Knowledge/Confidence of SSC at time 1 continued to predict suicidal ideation at time 2 when controlling for each 3ST informed covariate. The CLPM including psychological pain as the covariate found a medium negative cross-lagged effect of Knowledge/Confidence at time 1 predicting suicidal ideation at time 2 (Ã = -.10, p = .01), and a medium positive cross-lagged effect of psychological pain at time 1 predicting suicidal ideation at time 2 (Ã = .11, p = .009). There was also a large negative cross-lagged effect of Knowledge/Confidence at time 1 predicting psychological pain at time 2 (Ã = -.13, p = .002). All other cross-lagged effects were less statistically reliable (Ãs < |.08|, ps > .08). A CLPM including connectedness as the covariate found a large negative cross-lagged effect of Knowledge/Confidence at time 1 predicting suicidal ideation at time 2 (Ã = -.13, p = .003). There was also a large positive cross-lagged effect of Knowledge/Confidence at time 1 predicting connectedness at time 2 (Ã = .12, p = .004) and a medium positive cross-lagged effect of suicidal ideation at time 1 predicting connectedness at time 2 (Ã = .08, p = .04). All other cross-lagged effects were minimal and less statistically reliable (Ãs < |.04|, ps > .24). Finally, a CLPM including the pain â connectedness differential as the covariate found similar results, with a medium negative cross-lagged effect of Knowledge/Confidence at time 1 predicting suicidal ideation at time 2 (Ã = -.10, p = .03). There was also a large negative cross-121 lagged effect of Knowledge/Confidence at time 1 predicting pain â connectedness at time 2 (Ã = -.16, p < .001). All other cross-lagged effects were small and less statistically reliable (Ãs < |.06|, ps > .20). Robustness Checks As noted in Study 1, given that research findings can be sensitive to data analytic decisions, robustness checks are an important tool for helping to protect against potential researcher degrees of freedom (Klonsky, 2025; Nuijten, 2022; Olsson-Collentine et al., 2023; Steegen et al., 2016). As in Study 1, the original data analytic plan for Study 2 stated that the full score of the Beck Scale for Suicide Ideation (BSS) would be used to capture suicidal ideation. However, to more accurately measure suicidal ideation (see Christensen & Victor, in press), factor analysis was used to identify and sum items measuring suicidal ideation only. This resulted in a 7-item measure for analyses. Thus, as a robustness check and in the spirit of transparency, key analyses from Study 2 were also conducted using the total scale version of the BSS as originally proposed and are reported below. Main findings reported for CLPM analyses with the 7-item version of the BSS were also found when using the total BSS. There was a large positive cross-lagged effect of Maladaptive Frequency scale at time 1 predicting BSS total at time 2 (Ã = .13, p = .001), a large negative cross-lagged effect of Knowledge/Confidence at time 1 predicting BSS total at time 2 (Ã = -.12, p = .003), and small and less statistically reliable cross-lagged effects of Adaptive Frequency and Adaptive Variety scales at time 1 predicting BSS total at time 2 (Ãs < .06, ps >.09). Two new effects emerged when using the BSS total in CLPMs; there was a moderate positive cross-lagged effect of Maladaptive Variety scale at time 1 predicting time 2 BSS total (Ã = .10, p = .01), and a 122 moderate positive cross-lagged effect of BSS total at time 1 predicting Adaptive Frequency scale at time 2 (Ã = .07, p = .04). Together, these analyses suggest that key Study 2 findings (Maladaptive Frequency scale and Knowledge/Confidence at time 1 predicted suicidal ideation at time 2) appear robust across different ways of measuring suicidal ideation. Interestingly, additional positive findings emerged when using the full BSS as initially planned, though the failure of these findings to emerge when using the 7-item version suggest they may be fragile. 123 Discussion Suicide-specific coping (SSC) has been a central component of psychotherapy for suicide risk for more than three decades (Linehan, 1993). SSC is also a core component of safety planning interventions, which are recommended as best practice by the National Institute for Health and Care Excellence in the UK (NICE, 2022), the Centre for Addiction and Mental Health in Canada (CAMH, 2023), the Suicide Prevention Resource Center in the USA (2021), and broader empirical literature on suicide risk (Chu et al., 2015). Despite this centrality of SSC to suicide interventions and best practice guidelines, little research has examined SSC, resulting in an absence of empirical data and understanding regarding how individuals cope with and manage suicidal thoughts (Stanley et al., 2017). This dissertation contributes to this growing area of research by exploring key research questions about coping with suicidal ideation, including: what SSC responses are used, the perceived impact of these responses on suicidal ideation, and the actual associations of these responses with suicidal ideation. These questions were examined using a multimethod approach across two studies. Study 1 involved the use of a semi-structured clinical interview and self-report measures and examined SSC in 102 undergraduate students, all with a lifetime history of suicidal ideation. Study 2 used a longitudinal design with two time points, spaced one week apart, to examine SSC in 400 North American adults (recruited via Prolific) who had reported suicidal ideation in the past week. Due to the descriptive and exploratory nature of research questions, there were numerous potential findings to discuss (see Tables 4 â 7, 16). For this reason, findings are discussed in three parts. First, I provide a brief, high-level overview of findings. Second, I summarize what I 124 see as 11 key findings regarding different individual SSC responses examined. Third, I summarize findings regarding dimensions of SSC and suicidal ideation. This summary of results is followed by a discussion of differences in SSC across participant demographics and clinical characteristics. Finally, overall implications for research and clinical work, limitations, and important areas for future research are discussed. Overview of Findings Participants endorsed a wide range of SSC responses in both studies. Of the 36 responses assessed in Study 1 and the 32 in Study 2, every response was endorsed by at least some participants. In Study 1, most SSC responses were perceived by participants to reduce aspects of suicidal ideation; however, nearly every response also had at least some participants who perceived it to increase suicidal ideation. Despite the perceived helpfulness of most SSC responses in Study 1, Study 2 found that most SSC dimensions and individual SSC responses were unrelated to actual changes in suicidal ideation during the subsequent week. Notable exceptions included Frequency of Maladaptive SSC, which predicted increased next-week suicidal ideation, and Knowledge/Confidence in SSC, which predicted decreased next-week suicidal ideation. Four individual SSC responses were found to predict changes in next-week suicidal ideation, and there were also five SSC responses where suicidal ideation predicted changes in next-week coping. Only one SSC response (fantasizing about dying) exhibited a bidirectional relationship with suicidal ideation. These findings and others are discussed in detail below. 125 Individual Suicide-Specific Coping (SSC) Responses Reasons for living Reasons for living, or reasons for staying alive, are widely recognized as a key factor in clinical practice with suicidal individuals and the empirical literature (Bakhiyi et al., 2016; Klonsky et al., 2021; Linehan & Goodstein, 1983). Interestingly, not only was âthinking about reasons for livingâ a commonly endorsed SSC item in both studies (fourth and fifth most often used response in Study 1 and 2, respectively), this item was also perceived to be helpful by most participants. On an aggregated score of perceived reduction on overall suicidal ideation, thinking about reasons for living had the third highest score among the 36 items assessed in Study 1, suggesting it was perceived to reduce suicidal ideation more than most other SSC responses. Using this coping response more frequently was negatively associated with current suicidal ideation in both studies, with small to moderate sized effects. In Study 2, there was a cross-lagged effect suggesting that those with more intense suicidal ideation during the past week were less likely to think about reasons for living as a SSC response during the subsequent week. Together, these findings suggest that thinking about reasons for living may be a relatively common and helpful SSC response. This aligns with the emphasis placed on reasons for living in clinical and theoretical research. For example, reasons for living are a central focus in treatments designed to help suicidal individuals (e.g., Life worth living focus in DBT; Linehan, 1993) and in theories on suicidal ideation (e.g., Klonsky et al., 2021). However, it was also noted that in Study 1, a small proportion of individuals reported that thinking of reasons for living was actually perceived to increase desire to die (8%), decrease desire to live (8%), and increase suicide intent (2%). Although from a small portion of the sample, these discrepant results 126 underscore the importance of considering the unique impact any SSC response may have for an individual when incorporating SSC into clinical interventions. This caution is noted for reasons for living in particular when completing safety planning; if safety plan templates include a âReasons to Liveâ section, but an individual genuinely cannot identify reasons to live, this empty section may inadvertently serve as a reminder of their lack of reasons for living, thereby increasing distress (Stanley & Brown, 2019). Withdrawing from others Findings regarding âwithdrawing from others and staying aloneâ deserve special attention due to this SSC response being both very common and also very unhelpful. Of all SSC responses assessed, withdrawing from others was perceived to be the least helpful in reducing suicidal ideation (and was in fact perceived to increase suicidal ideation for a substantial portion of participants). Withdrawing from others and staying alone was also the most frequently used SSC response across both studies. Seventy-one percent of participants in Study 1 reported engaging in this SSC item usually or always when suicidal, and 53% in Study 2 reported that they had done this usually or always when suicidal in just the past week. This SSC response was cross-sectionally related to suicidal ideation, with small to moderate sized positive associations observed with worst-point ideation in Study 1 and past week suicidal ideation in Study 2. However, there was no longitudinal relationship observed between withdrawing from others during the past week and suicidal ideation during the subsequent week in Study 2. These results align with the strong link documented in the literature between suicidal ideation and social isolation, withdrawal, and loneliness (Durkheim, 1897; Motillon-Toudic et al., 2022; Van Orden et al., 2010). From a cognitive-behavioral lens, it is also perhaps 127 unsurprising to find that individuals commonly withdrew from others when suicidal, as this behavior is among action urges associated with negative affect (also described as a âmood dependentâ behavior; Linehan, 2015). Interestingly, Study 2 analyses did not find cross-lagged effects between this coping item and suicidal ideation over a one-week period. This pattern of results suggests that although withdrawing may increase suicidal ideation in the moment (at least as subjectively perceived by participants in Study 1), this impact on subsequent suicidal ideation may not occur over a week-to-week period of time. Further research should investigate potential iatrogenic effects of social withdrawal as a coping response to suicidal ideation, given the prevalence of this behavior. Fantasizing about dying Another SSC response that was observed to be both common and unhelpful was âfantasizing about dyingâ. Although only assessed in Study 2, this was the fourth most commonly used SSC response, with 27% of participants reporting that they fantasized about dying usually or always when suicidal in the past week. Interestingly, this was the only SSC variable to demonstrate a reciprocal relationship with suicidal ideation. Specifically, more frequently fantasizing about dying when suicidal in the past week was found to predict more intense suicidal ideation during the next week, and more intense suicidal ideation during the past week was found to predict more frequent fantasizing about dying during the next week. One possible interpretation of these results is that more intense ideation may lead to difficulties disengaging from oneâs ideation. Perhaps in support of this, those with more intense suicidal ideation during the past week were also found to be less likely to use a SSC response that 128 involved disengaging from suicidal ideation (âignoring or suppressing suicidal thoughtsâ) during the subsequent week. These patterns draw attention to how an individual may cognitively engage (or disengage) with their suicidal thoughts and the relationship between that engagement and suicidal ideation. Specifically, results suggest that suicidal ideation intensity may impact how one responds to their own suicidal thoughts; more intense ideation may further oneâs likelihood of dwelling or ruminating on such thoughts, while less intense ideation may make it easier for an individual to disengage from or ignore those thoughts. These results align with research on âdaydreaming about deathâ, which was found to predict increased suicidal thoughts longitudinally (Selby et al., 2007), and also with an emerging focus in the literature on suicide-specific rumination (Rogers et al., 2021, 2022). Suicide-specific rumination, a repetitive mental fixation on oneâs suicidal thoughts and intentions, has demonstrated moderate to large associations with suicidal ideation (Rogers et al., 2021), appears to be associated with suicide attempts (Rogers et al., 2022) and also has been found to predict future suicide intent (Rogers et al., 2021). Meta-analytic evidence from the broader literature on emotion regulation also finds that rumination is among emotion regulation strategies most strongly related to general psychopathology (Aldao et al., 2010). This research, taken together with results from the dissertation on these SSC responses, highlights the potential importance of considering how individuals cognitively respond to suicidal thoughts. This would thus lend further support for the value in incorporating cognitively focused interventions when working with suicidal individuals (e.g., Cognitive Behavior Therapy, Beck, 2020; defusion techniques in Acceptance and Commitment Therapy, Hayes et al., 2011; externalizing of suicidal thoughts in DBT, Aguirre & Galen, 2013). 129 One additional interpretation of these findings to note is the potential that the SSC response of fantasizing about dying may simply capture experiences of more intense ideation. For example, it may be that fantasizing about dying is conceptually part of more severe experiences of suicidal ideation, and thus the bidirectional relationship with the measure of suicidal ideation intensity in this study is explained by the relationship between experiences of suicidal ideation over time. Nonsuicidal self-injury (NSSI) There is a substantial literature on the relationship between NSSI and suicidal ideation. On one hand, systematic reviews and meta-analysis of the literature find that engaging in NSSI predicts future suicidal ideation (Hamza et al., 2012; Ribeiro et al., 2016). On the other hand, more recent longitudinal work draws attention to the importance of timescale. NSSI has actually been found to predict decreases in suicidal ideation in subsequent hours (Herzog et al., 2022), thus perhaps serving an âanti-suicideâ function (Klonsky, 2007) in the short term. This dissertation adds further knowledge to the relationship of NSSI and suicidal ideation by examining NSSI that is engaged in specifically for the purpose of coping with suicidal ideation. In Study 1, 64% of the sample had âengaged in NSSIâ at least once as a way to cope with suicidal thoughts, and 13% reported doing this usually or always when suicidal. Interestingly, NSSI was also perceived as the fifth least helpful SSC response for reducing overall suicidal ideation. Perceived impact across facets of suicidal ideation was varied; more participants perceived NSSI to increase desire to die (27%) compared to decrease desire to die (23%), but more perceived it to decrease suicide intent (47%) compared to increase suicide intent (17%). 130 This pattern points to the potential distinct impacts that NSSI can have on components of suicidal ideation. In Study 2, NSSI was a relatively uncommon SSC response used; however, it was still used more frequently compared to other often recommended SSC responses, including talking with a therapist, grounding skills, means safety, contacting a crisis center, or using a safety plan. Study 2 found a positive cross-sectional association between engaging in NSSI as a SSC response during the past week and suicidal ideation. However, no longitudinal relationship was observed between engaging in NSSI as a SSC response in the past week and suicidal ideation during the following week. Further research is needed to build on these findings and further clarify the relationship of NSSI engaged in for the purpose of coping with suicidal ideation and the relationship this coping response has on subsequent experiences of suicidal ideation over varying timeframes. Means safety In both studies, âreducing access to means/methods that could be used for suicide attemptsâ (i.e., means safety), was among the least commonly used SSC responses. Because each study asked participants about coping with suicidal thoughts regardless of ideation intensity, low endorsement of this SSC response is perhaps unsurprising given that means safety may only be used in times of peak suicidal ideation or âcrisisâ. Interestingly, Study 2 found a medium cross-lagged effect whereby engaging in means safety in the past week predicted more intense suicidal ideation during the following week. This finding is noteworthy, as most research on means safety focuses on suicidal behavior (e.g., suicide attempts, suicide rates) or suicide capability (Anestis et al., 2017; Jin et 131 al., 2016), with less consideration for the impact of means safety on suicidal ideation. It is unclear why engaging in means safety would have predicted greater suicidal ideation; however, one possible interpretation of this result could be due to an unaccounted third variable. It may be that individuals who engage in means safety are more likely to have some degree of suicide intent, planning or capability, which may be why they engage in means safety in the first place (e.g., a person with zero intent to kill themselves is unlikely to need to take steps to make their environment safer). It is possible that the predicted increase in subsequent suicidal ideation may be driven by an unmeasured greater baseline severity of suicidal intent, behaviors, or capability (e.g., aspects distinct from the construct of suicidal ideation). Though this finding is from one study only (and thus limits confidence in drawing conclusions from this observed effect), the relationship between means safety and suicidal ideation may potentially be an important one to further examine in future research given how commonly means safety is suggested as a way to reduce suicide risk (Anestis et al., 2016). If there are, in fact, some adverse effects of this response (e.g., making the environment safer unintentionally results in further thinking about ways to act on suicidal thoughts and leads to more severe suicidal ideation), this would be important to explore. Risk-taking behaviors Another relatively infrequent SSC response found to be longitudinally related to suicidal ideation was âengaging in risk-taking behaviorsâ (e.g., driving too fast, unprotected or aggressive sexual behavior, putting oneself in situations with unnecessary risk). Only 4% of participants reported doing this usually or always in the past week when suicidal (this SSC item was not assessed in Study 1). However, there was a strong cross-lagged effect where more frequent risk-132 taking behaviors in the past week predicted more intense suicidal ideation during the following week. The present study is not the first to find a relationship between risk-taking behaviors and suicide-related variables. In a large sample of US soldiers with lifetime ideation (n=3,916), engaging in risk-taking or âtempting fateâ behaviors was found to be a relatively strong predictor of making a suicide attempt (Nock et al., 2018). Taken together, these results highlight the potential importance of noting risk-taking behaviors as a SSC response and the potential harmful impacts of this response. Finding someone understanding Among all SSC items assessed in Study 1, âfinding someone understandingâ was notable for being perceived as the most helpful response for reducing suicidal ideation (as determined by the highest aggregate score of perceived impact on suicidal ideation). Most participants who engaged in this response perceived it to decrease desire to die (87%), increase desire to live (76%), and decrease suicide intent (74%). Due to the overlap this SSC item had with other items involving social and relational support, it was not assessed in Study 2. Although not perceived to be as helpful, these additional items assessing social support were also perceived to be generally helpful at reducing suicidal ideation (e.g., talking with a therapist/health professional; talking with a friend or family). Interestingly, Study 2 found that use of these social support responses over the past week was not cross-sectionally associated with suicidal ideation (with the exception of socializing and not mentioning suicidal thoughts, which had a small negative association with ideation). Furthermore, none of these items were longitudinally related to next week suicidal ideation. Although findings present a somewhat mixed picture, the overwhelmingly positive impact perceived in Study 1 highlights the potential protective nature of social support for 133 suicidal ideation that has been previously emphasized in the literature on suicidal ideation (Otten et al., 2022) and attempts (Kleiman & Liu, 2013). Exercise/recreational physical activity Although relatively uncommon in both Study 1 (25% reported doing this usually or always) and Study 2 (12% reported using this usually or always), participants who engaged in âexercise/recreational physical activityâ when suicidal perceived this SSC response to be largely helpful. In fact, this was one of the only SSC responses out of the 36 assessed in Study 1 where not a single participant perceived it to increase desire to die or suicide intent. This pattern, where exercise represents a relatively uncommon, but relatively helpful, coping response has also been observed in research assessing coping responses for resisting NSSI urges (Klonsky & Glenn, 2008). Interestingly, Study 2 found no cross-sectional or longitudinal relationship between engaging in exercise as a SSC response and suicidal ideation. On one hand, these results may suggest that perceived impacts of coping do not necessarily translate into actual reductions in ideation. On the other hand, it is also possible that Study 2 simply did not capture the appropriate timeframe in which to observe these changes given that Study 1 assessed more immediate perceived impacts on ideation and Study 2 impacts from one week to the next. Further research is needed to clarify the extent to which exercise may be a helpful SSC response over different timeframes. Crisis Center An interesting pattern emerged regarding the perceived impact of âcontacting a crisis centre or help lineâ as a SSC response. In both studies, contacting a crisis center when suicidal 134 was a relatively uncommon coping response (e.g., fifth and third least common in Study 1 and 2, respectively). This SSC response was also rated as the sixth least helpful response in Study 1 among the 36 assessed (according to perceived impact on overall suicidal ideation). When looking at individual facets of ideation, contacting a crisis center was perceived to decrease suicide intent for 52% of participants, decrease desire to die for 32%, and increase desire to live for 27%. However, 26% of participants perceived it to increase desire to die and 6% perceived it to increase suicide intent. Results from Study 2 found no effect to suggest that contacting a crisis center in the previous week predicted subsequent suicidal ideation. However, there was a cross-lagged effect where participants who were more suicidal in the past week were more likely to contact a crisis center when suicidal during the subsequent week. These longitudinal analyses suggest that those who contact a crisis centre as a SSC response may be more severely suicidal. These mixed results regarding the impact of crisis center use emphasize the need for further research on this important resource for suicidal individuals. Indeed, a recent review of the effectiveness of crisis line services found the overall quality of studies to be poor, limiting a clear understanding of these services (Hoffberg et al., 2020). Similar to the somewhat mixed support found in this dissertation, this review found general support for crisis center effectiveness, but also some evidence of potential iatrogenic effects. For example, one study found âsuicidal urgencyâ to increase in approximately 8% of calls (Mishara et al., 2016). Although results from this dissertation, alongside previous research, suggest that crisis centers are a relatively uncommon SSC response (Simon et al., 2016), future research on this is important, as results from this dissertation also suggest that those who utilize these services tend to be more severely suicidal. 135 Grounding skills Another interesting finding concerns the relatively low endorsement of âusing strong sensations to ground yourself (e.g., cold water, ice)â when suicidal in both studies. This SSC response is one of several âcrisis survivalâ skills taught in DBT (i.e., part of the TIPP skill; Linehan, 2015), and thus the low endorsement could reflect infrequent periods of âcrisisâ or particularly intense suicidal ideation that would require its use. On the other hand, the relatively infrequent use observed in each study may also suggest that grounding skills are not a well-known coping response for tolerating distress, including distress that often accompanies suicidal ideation. When examining the perceived impact of this SSC response, over half of the participants who had used it in Study 1 reported perceiving it to decrease both desire to die and suicide intent. Although no participants perceived this SSC response to increase desire to die, one participant perceived it to increase suicide intent. Results from Study 2 found no effects to suggest a longitudinal relationship between frequency of this SSC response and suicidal ideation from one week to the next. These results, like others, highlight the unique impacts that SSC responses can have person to person, and also the potential importance of the timeframe when examining the impact of SSC on suicidal ideation. Using a mobile app to cope A final SSC response to note was âusing a mobile app designed for copingâ. Results from Study 1 suggest that relatively few individuals used an app designed for coping when suicidal. Specifically, this was the third least commonly used coping response among the 36 assessed, with only 15% of participants reporting that they had ever used an app to cope when suicidal, and 1% reporting that they used an app usually or often to cope when suicidal. These results are 136 noteworthy, and perhaps discouraging, in light of the plethora of mobile apps that have been developed specifically for suicide prevention and coping (e.g., a recent systematic review identified 80 existing suicide prevention apps; Jha et al., 2025). This review also found evidence of difficulties with attrition in digital intervention studies (Jha et al., 2025). Thus, while mobile apps designed to enhance SSC may appear to hold great promise for suicide prevention â being easily accessible and with options for personalized coping â they may be limited in effectiveness due to low endorsement and actual engagement, as suggested by this dissertation and the broader literature (Baumel et al., 2019; Jha et al., 2025). Dimensions of SSC and Suicidal Ideation Cross-Sectional Relationship of SSC Dimensions and Suicidal Ideation The cross-sectional relationship between SSC dimensions and suicide-related variables was examined in both studies. As hypothesized, maladaptive SSC dimensions were positively correlated with all suicide-related variables in both studies. There were small to moderate associations between Maladaptive scales (Frequency and Variety) and current suicidal ideation in both studies, and worst-point ideation and suicide attempt history in Study 1. These results suggest that those who engaged in more frequent and numerous maladaptive coping responses when suicidal (e.g., NSSI, substance use, withdrawing from others) also reported higher levels of current suicidal ideation, worst point ideation, and were more likely to have a suicide attempt history. Although this dissertation was one of the first to examine maladaptive SSC, results align with positive associations found in previous research between styles of maladaptive coping and suicide-related variables (Guerreiro et al., 2013). 137 Hypotheses regarding adaptive SSC dimensions were partially supported. As hypothesized, Knowledge/Confidence in SSC had moderate to strong negative associations with current ideation in both studies, and Adaptive scales (Frequency and Variety) had small negative associations with suicidal ideation in Study 2 at time 1 (but was not associated with ideation at time 2). In contrast to hypotheses, Study 1 found that Knowledge/Confidence in SSC was not associated with suicide attempt history, and Adaptive scales (Frequency and Variety) had small to moderate positive associations with worst-point ideation and suicide attempt history. This mixed pattern of results mirrors, to some extent, inconsistencies found in the literature between adaptive styles of coping and suicide-related variables (Guerreiro et al., 2013; Speckens & Hawton, 2005). Interpretation of these correlations is challenging given their cross-sectional nature. For example, a positive relationship between adaptive SSC and suicide attempt history does not necessarily reflect that these coping responses are unhelpful; it may instead reflect that those with a more severe suicide history simply needed to engage in more coping because of this. Another possibility is that, although rated by experts as âadaptiveâ, not all adaptive SSC items may be truly adaptive when used in certain contexts or with increasing frequency. In tentative support of this possibility, longitudinal analyses found a moderate sized effect where more frequent use of the adaptive SSC item âengaging in a positive activity (e.g., a hobby, watching a TV show/movie, playing video games, spending time with a pet, reading, etc.)â predicted increased suicidal ideation during the subsequent week. Although these activities are largely considered âpositiveâ, it is possible that at higher frequencies of use, this SSC response becomes a form of avoidance from engaging in meaningful activities or confronting situations ultimately contributing to suicidal ideation, thus furthering ideation intensity over time. Such mixed results 138 require further investigation, particularly in sample sizes with adequate power to reliably detect effects of small to medium magnitude. Longitudinal Relationship of SSC Dimensions and Suicidal Ideation Study 2 examined the longitudinal relationship between SSC dimensions (Frequency, Variety, and Knowledge/Confidence) and suicidal ideation from one week to the next. This is, to my knowledge, the first study to examine the bidirectional relationship between SSC and suicidal ideation. I utilized cross-lagged panel model (CLPM) analyses to examine the extent to which one variable predicted change in the other across time (i.e., cross-lagged effects) while also accounting for the stability in each variable across time (i.e., autoregressive effects). Main findings from these analyses were that among dimensions of SSC, only past-week Maladaptive Frequency and Knowledge/Confidence predicted next-week suicidal ideation. When included in the same CLPM, each of these two SSC dimensions continued to predict suicidal ideation at time 2. There was no evidence of a bidirectional relationship for any SSC dimensions. In other words, suicidal ideation did not appear to predict next-week SSC dimensions in this study. These findings are discussed below. Maladaptive Frequency of SSC. Results from Study 2 found that participants who used Maladaptive SSC responses more frequently in the past week were more likely to experience greater suicidal ideation during the subsequent week. This effect was maintained after accounting for a range of covariates, including accounting for oneâs knowledge and confidence in coping with suicidal ideation, general approach and avoidance coping responses, distress tolerance, and social connection. Maladaptive Frequency no longer predicted next week suicidal ideation when accounting for emotion regulation abilities, psychological pain, and the relative 139 difference between pain and social connection, suggesting that Maladaptive SSC may impact future suicidal ideation through its impacts on emotion regulation and psychological pain. This pattern of results highlights the potential relationship between Maladaptive SSC responses and future suicidal ideation from one week to the next. Although no research to date has previously examined the longitudinal relationship between Maladaptive SSC and suicidal ideation, these results may not be surprising given that maladaptive general coping responses have been linked longitudinally with suicidal ideation in previous research. For example, there is evidence of a relationship between suicidal ideation and engaging in NSSI (Ribeiro et al., 2016), substance use (Zhang & Wu, 2014), and eating disorder-related behaviors (Joiner et al., 2022). Results also suggest that experiences of negative affect, namely the presence of emotional pain and difficulties with regulating emotions, may play a role in the relationship between Maladaptive SSC and suicidal ideation. These findings align with suicide theory, which emphasizes the importance of painful experiences, including negative emotions, and subsequent intensity of suicidal ideation (see 3ST, Klonsky et al., 2021). Future research with additional time points would be well suited to further explore these relationships, including a potential mediating role of negative affect, and/or regulation of negative affect, in explaining the relationship between Maladaptive SSC and suicidal ideation. Knowledge/Confidence SSC. A key finding to emerge from Study 2 was that participants who reported higher levels of knowledge and confidence in coping with their suicidal ideation (measured using the Suicide-Related Coping Scale; SRCS; Stanley et al., 2017) in the past week also tended to experience less intense suicidal ideation during the subsequent week. Knowledge/Confidence in SSC continued to predict next-week suicidal ideation 140 controlling for each covariate, including general approach and avoidance coping, distress tolerance, emotion regulation, psychological pain, social connection, and the differential score of psychological pain versus social connection. The uniqueness of the relationship between Knowledge/Confidence in SSC and next week suicidal ideation builds on previous research emphasizing knowledge and confidence in coping with suicidal ideation as an important construct (Stanley et al., 2017; Interian et al., 2021; Rainbow et al., 2023; Glatt et al., 2025). Only one previous study has examined the longitudinal relationship between the SRCS and suicide outcomes, over a period of 3 months (Interian et al., 2021). Thus, results from Study 2 add novel information to this literature and suggest that knowledge and confidence may predict less intense suicidal ideation across an even shorter timeframe of one week to the next. Given the ubiquity of this timeframe in outpatient psychotherapy settings, this finding may support the importance of considering a clientâs knowledge and self-efficacy in coping with their suicidal ideation when assessing suicide risk. Differences in SSC across Demographic and Clinical Characteristics Finally, exploratory analyses revealed several differences in SSC across demographic and clinical characteristics. A significant limitation of these analyses was the small sample size in subgroups. This resulted in underpowered follow-up analyses in Study 2, but also the collapsing of multiple demographic categories into one group (e.g., one ânot straightâ group, despite important differences across distinct queer sexual orientations) in both studies in order to maximize power. As a result, these findings should be interpreted cautiously. Overall, no differences in SSC were observed across age or gender in either study. In both studies, having a history of mental health treatment was associated with higher scores on 141 both Adaptive and Maladaptive SSC dimensions. Study 1 found that White participants reported greater Adaptive and Maladaptive SSC compared to participants of East Asian descent, and that those who reported English as a primary language also reported greater scores on Adaptive SSC dimensions. In Study 2, currently being in a relationship, having a Bachelorâs degree or higher level of education, and higher annual income was associated with greater scores on Adaptive SSC dimensions, and reporting a sexual orientation that was not straight (e.g., queer, bisexual, gay, asexual) was associated with greater scores on Maladaptive SSC dimensions. Interestingly, Study 1 found that participants who reported on use of SSC during the pandemic reported using a greater Variety of Adaptive and Maladaptive SSC compared to participants who reported on SSC before the pandemic. These results contribute to a growing literature on coping and suicidal ideation across different populations. For example, differences in SSC observed between White and East Asian participants in Study 1 may in part reflect differences in help seeking or accessing mental health treatment, as research has previously found differences between East Asian and White populations in seeking mental health services (Tiwari & Wang, 2008). The lack of differences observed across gender contrasts with previous research examining confidence in SSC, where small differences emerged with men reporting greater levels of confidence in certain SSC responses compared with women (Czyz et al., 2016). In addition, differences observed across sexual orientation, relationship status, education, and income are interesting given that these demographic factors and social determinants of health have been linked with suicide-related variables in previous research (Batterham et al., 2025; Na et al., 2025). These findings highlight the importance of further exploring SSC in individuals from diverse backgrounds in future research. 142 Key Implications Given the abundance of descriptive data provided by this dissertation and analyses that feature both individual SSC responses and dimensions of SSC, results offer a number of important implications for future research and clinical work. Below, four overarching implications from this dissertation are discussed. Individuality of SSC First, results from Study 1 emphasize the highly individualistic experience of coping with suicidal ideation. Not a single SSC response was unanimously perceived to increase or decrease any aspect of suicidal ideation by participants. Although certain coping responses were largely perceived to reduce suicidal ideation (e.g., seeking social support from someone understanding), or largely perceived to increase suicidal ideation (e.g., withdrawing from others and staying alone), there was variability even amongst these responses. There was also variation observed regarding the perceived impact of SSC amongst the facets of suicidal ideation assessed. For example, engaging in means safety was perceived to decrease suicide intent for 77% of participants. However, only 23% perceived it to decrease desire to die. These patterns further illuminate the nuances and complexity of SSC and add to a small yet growing literature on individual differences in SSC (Kuehn et al., 2022; Simon et al., 2016). Together, findings highlight the importance of taking a client-centered, individualized approach to SSC. Psychoeducation of SSC The descriptive information provided by this dissertation regarding SSC use and perceived impact may also be relevant in clinical settings when implementing safety planning 143 interventions or managing suicide risk. For example, providing psychoeducation about the perceived impact of coping responses may be a useful motivational enhancement strategy for encouraging suicidal individuals to try less-often used, but helpful, coping responses (e.g., informing a client that although relatively few people exercise to cope with suicidal thoughts, most people who do find it helpful), and for reducing the use of common, but harmful, coping responses (e.g., withdrawing from others). In the words of one participant from Study 1, âThis study is very useful, even though a lot of this info is common sense, it's useful to have research to support and back it up. It might encourage people to cope moreâ. Findings from this dissertation could thus be readily integrated into existing interventions that are designed to target motivation enhancement in this population, including commitment strategies in DBT (Linehan, 1993) and motivational interviewing (MI) strategies in safety planning interventions (Micol et al., 2022). Maladaptive SSC predicts Suicidal Ideation A third key implication of this dissertation concerns the pattern of findings for Maladaptive SSC responses. Results draw attention to the relationship between more frequent use of maladaptive coping responses when suicidal and experiencing more intense suicidal ideation during the subsequent week. These findings are notable when considering that, to my knowledge, existing research has only examined adaptive SSC responses. Thus, an implication of this dissertation is that by only considering adaptive SSC, an important aspect of coping with suicidal ideation is being missed. This is especially critical given that results from this dissertation also suggest that some maladaptive responses (e.g., withdrawing from others, fantasizing about dying) appear to be very common. Future research must further investigate 144 Maladaptive SSC and its impact on suicidal ideation and other suicide-related outcomes of interest. These results also align with recommendations from the broader literature to pay attention to maladaptive coping (in addition to adaptive coping) in research and clinical work. For example, researchers have suggested that interventions should focus on reducing maladaptive coping responses, not just increasing use of adaptive responses, given that a more consistent relationship is found between general maladaptive coping and psychological distress (Horwitz et al., 2011; Southward et al., 2023). In the context of DBT, a recent study found that decreases in maladaptive coping frequency were more consistently associated with broader improvements (compared to increases in adaptive coping; Southward et al., 2023). The importance of targeting maladaptive coping responses also fits with the treatment hierarchy proposed in DBT, where maladaptive behaviors (i.e., life-threatening behaviors, therapy-interfering behaviors, quality-of-life interfering behaviors) are targeted before adaptive behaviors (i.e., increasing use of skills). Together, findings from this dissertation and the broader literature highlight the importance of assessing for the presence and impact of maladaptive SSC in clinical work and research. Knowledge and Confidence in SSC A fourth implication for future research and clinical work concerns the significance of knowledge and confidence in coping with suicidal thoughts. The measure that assessed knowledge and confidence in SSC (SRCS; Stanley et al., 2017) was the only SSC variable which continued to predict next-week suicidal ideation regardless of which covariates were controlled for (general coping, distress tolerance, emotion regulation, psychological pain, connection to 145 others). The robustness of this finding speaks to the potential importance of knowledge and self-efficacy in coping with suicidal ideation when considering future experiences of suicidal ideation. These results add to a growing literature on examining knowledge and confidence in SSC (Czyz et al., 2016; Stanley et al., 2017; Interian et al., 2021; Rainbow et al., 2023; Glatt et al., 2025). Knowledge and confidence in coping with suicidal thoughts appears to be a meaningful construct for future research to further examine and for clinicians to consider when working with suicidal individuals. Limitations While this dissertation has notable strengths and utility, there are important limitations to note. Firstly, there are limitations concerning reliability of findings. Although this study provided a detailed account of SSC responses, much of this information in Study 1 (i.e., information about perceived impact) was only reported by participants who had endorsed using that SSC response at least once. This resulted in sample sizes that ranged from 12 â 97 participants for some of the descriptive results reported in Study 1. As such, the reliability of some findings may be limited, and it is important to keep these small sample sizes in mind when interpreting results. Another important limitation concerns the generalizability of these results to other populations or settings. Study 1 was composed of a sample of 102 undergraduates from the University of British Columbia, located in Vancouver, Canada. As such, findings regarding the 36 SSC responses assessed may not be generalizable to other undergraduate populations or additional populations of importance, such as individuals across the lifespan or in psychiatric settings. Although Study 2 utilized a sample of adults across the lifespan who were suicidal in the past week, this sample was restricted to adults on Prolific who were currently living in North 146 America. As such, it is unclear the extent to which findings may apply to different countries or cultures, or to different settings such as psychiatric or clinical settings. Also limiting potential generalizability of findings are limitations due to potential sample bias in Studies 1 and 2. Both studies were advertised as studies that examined coping and mental health. As such, it is possible that individuals who were more comfortable discussing or reporting on their mental health and coping, and thus potentially more comfortable reporting on SSC by extension, were overly represented. Thus, research findings may be less generalizable to populations that are less likely to disclose or discuss mental health and suicide-related information. Although this limitation applies to most suicide research, it is important to be reminded of it in the context of SSC, given that individuals who do not disclose suicide-related content may be at elevated suicide risk (Podlogar et al., 2016). Another potential bias to note in the dissertation are limitations regarding potential impacts of memory bias when reporting on SSC experiences (Paulhus & Vazire, 2007). This is particularly relevant for Study 1, where participants were asked to report on their experiences of coping with suicidal ideation throughout all times in their life when suicidal. For some participants, this involved reporting on coping with suicidal thoughts in just the past year; for others, this involved reporting on more distant histories of suicidal thoughts (e.g., during adolescence). This may have impacted the accuracy of reporting on SSC experiences, and in fact, there were several participants (n=8) in Study 1 who had missing data for certain SSC items due to difficulties in remembering if they had used a response and/or what the perceived impact was. There are also several limitations to make note of that involve measurement. These limitations regarding measurement apply to the broader literature on SSC as well, given that there are only two measures which assesses SSC, and both specifically focus on confidence in 147 coping (Czyz et al., 2016; Stanley et al., 2017). For this reason, in order to assess the frequency, variety, and perceived impact of SSC, an interview-administered measure and self-report measure were developed for this dissertation (see Appendices A and B). Because the main aim of this dissertation was to describe the nature of SSC and explore the relationship between SSC and suicidal ideation, an in-depth focus on measurement development and validation was not included. However, it is important to note that the present dissertation was limited in that these dimensions of SSC were not assessed with previously developed and validated measures of SSC. It will be important for future research to focus on to improving understanding of the construct of SSC, including the potential formative versus reflective nature of SSC and the utility of measuring different dimensions of SSC. Another measurement-related limitation involved the categorization of SSC responses as âadaptiveâ or âmaladaptiveâ. This was done given the tendency to refer to coping with these categories in past research and the also clinical utility of examining these categories. To do this, expert clinical ratings were provided, and items were rated in terms of whether they were considered adaptive or maladaptive for most individuals. However, it is certainly possible that an adaptive item could be considered maladaptive, and a maladaptive item considered adaptive, given a certain context and/or individual. For example, an individual in a suicidal crisis may engage in NSSI in order to prevent themselves from making a suicide attempt. Thus, from the perspective of keeping the person alive, NSSI would be considered in this example as adaptive. However, this was an example of a SSC response rated as maladaptive for most individuals by experts. Furthermore, a portion of items did not have agreement from expert ratings (e.g., Using social media, Ignore/suppress suicidal thoughts; see Appendices A and B for full details). 148 Limitations from categorizing coping responses as strictly adaptive or maladaptive are also raised in the broader literature (e.g., âfallacy of uniform efficacyâ, Bonanno & Burton, 2013). Instead of an adaptive or maladaptive categorization, this research has suggested assessing flexibility of coping. Although this dissertation examined the overall number of responses used (an individualâs coping ârepertoireâ) to capture flexibility in coping, this is only one method of assessing flexibility. As such, it may not have fully captured the extent to which an individual flexibly used SSC responses across contexts, or the degree to which responses were revised if not helpful in the first place. Future research should seek to further explore coping flexibility and ways of measuring or capturing flexibility (Bonanno & Burton, 2013; Aldao et al., 2015) to better understand how individuals effectively (or ineffectively) cope with suicidal ideation. An additional measurement limitation concerned the measurement of SSC compared with general coping responses. One of the research questions in Study 2 examined the extent to which SSC was uniquely related to suicidal ideation when accounting for general coping as a covariate. To examine this, measures of general coping (the Brief COPE, distress tolerance, emotion regulation) were included as covariates. Despite the overall focus on coping, these covariate measures are not necessarily directly comparable to the SSC measures in this study. For example, the general avoidance coping scale (also referred to in the literature as âmaladaptiveâ scale) included items capturing denial and behavioral disengagement, which differed from the content of maladaptive SSC items, which captured responses such as substance use, NSSI, or withdrawing from others. Results are thus limited in the extent to which they speak to whether SSC is truly distinct compared to how one copes with stress, emotions, or distress in general. 149 A final set of limitations involved Study 2 specifically. First, there were limitations concerning inadequate power for certain analyses in Study 2. Although Study 2 was adequately powered to detect moderate to large cross-lagged effects, it was underpowered for detecting small effects, for analyzing models with more than one covariate included at a time, and for comparing the relationship between SSC and suicidal ideation across different demographic and clinical subgroups. It would be beneficial for future research to collect data from larger samples to address these statistical limitations. In addition, the methodological design of Study 2 carries certain limitations. In using a longitudinal design with time points spaced one week apart, results can only speak to the relationships between SSC and suicidal ideation over this period of time. As noted earlier, there are many additional timeframes that are important to understand (e.g., minutes, hours, days). In fact, prominent suicide theory is explicit that meaningful changes in suicide risk happen over these short timeframes (Klonsky et al., 2021). Finally, although the design of Study 2 allowed for the use of CLPM (a valuable approach for exploring longitudinal relationships), it is important to acknowledge the limitations of this statistical approach. As Hamaker, Kuiper, and Grasman (2015) emphasize, CLPM fails to separate within- and between-person variance, which can lead to potentially biased estimates of cross-lagged effects. In other words, CLPM analyses in this study do not account for the possibility that some individuals may have chronically higher or lower levels of suicidal ideation and/or engagement in SSC. This stable, between-person variance could contaminate estimates of how these variables predict each other over time. As such, it remains unclear the extent to which the longitudinal results observed are accounted for by within-person processes or between-person differences, and the extent to which the cross-lagged effects observed may be 150 overestimated. To address this limitation, future research should prioritize designs with three or more measurement occasions, which would allow for Random Intercepts CLPM (RI-CLPM), an extension of CLPM. RI-CLPM would allow for separation of within- and between-person differences (Hamaker et al., 2015), thus allowing for a more accurate assessment of the relationship between SSC and suicidal ideation over time. Future Directions Findings from this dissertation provide numerous opportunities for further exploration and examination of SSC. First, many individual items are worth investigating further given their significance in the suicide research field (e.g., crisis center use, reasons for living, NSSI, substance use, socializing, means safety, etc.). Second, future research should consider examining SSC across different timeframes and with additional waves of data to allow for more nuanced statistical approaches (e.g., RI-CLPM) to further knowledge regarding how these experiences operate across various periods of time. Third, it will be important for research to more closely examine psychometric properties and further advance measurement of SSC, including its different dimensions. Fourth, given the differences observed in SSC across participant characteristics, it is critical for future research to examine SSC across additional populations, including individuals diverse in clinical severity, ethnic and racial background, sexual and gender identity, and socioeconomic and education backgrounds. Finally, although this study was interested in the relationship between SSC and suicidal ideation, other suicide-related variables are important to consider, including suicide preparations or plans, suicide attempts, and suicide death. 151 Conclusion In summary, findings from this dissertation help shed light on patterns regarding most and least commonly used responses for coping with suicidal ideation, how they are perceived to impact suicidal ideation, and how these responses relate to and predict changes in observed suicidal ideation. My hope is that the rich descriptive data (e.g., Tables 4 â 7, 16) stimulate important research and clinical questions about SSC that others can pursue. In addition, longitudinal results from Study 2 offer valuable insight into the relationship between SSC and suicidal ideation across time. Specifically, that maladaptive SSC and knowledge/confidence in SSC appear to predict next-week experiences of suicidal ideation. Findings contribute to a growing and exciting new area of research, adding to the fieldâs foundation of knowledge regarding how individuals cope with suicidal thoughts. This area of research carries significant clinical implications given the centrality of SSC in psychological interventions for suicidal folks. As such, in addition to important research implications, findings may benefit health care providers tasked with managing and treating suicidality and also provide useful information to individuals with lived experience of suicidality seeking to better understand how to cope with their suicidal thoughts. To echo the sentiment shared by the late Dr. Barbara Stanley, a prominent figure in establishing research on coping with suicidal ideation, âitâs not the ideation itself that results in suicide attempts but what you are able to do in the face of ideationâ (B. Stanley, personal communication, January 14, 2019). Ultimately, enhancing understanding of how people cope with suicidal ideation may be a key pathway to preventing suicide and supporting the well-being of the millions of people worldwide at risk for suicide. 152 References Aguirre, B., & Galen, G. (2013). Mindfulness for borderline personality disorder: Relieve your suffering using the core skill of dialectical behavior therapy. New Harbinger Publications. Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30(2), 217â237. https://doi.org/10.1016/j.cpr.2009.11.004 Aldao, A., Sheppes, G., & Gross, J. J. (2015). Emotion Regulation Flexibility. Cognitive Therapy and Research, 39(3), 263â278. https://doi.org/10.1007/s10608-014-9662-4 Alexander, M. J., Haugland, G., Ashenden, P., Knight, E., & Brown, I. (2009). Coping With Thoughts of Suicide: Techniques Used by Consumers of Mental Health Services. 60(9). Althouse, A. D. (2016). Adjust for Multiple Comparisons? Itâs Not That Simple. The Annals of Thoracic Surgery, 101(5), 1644â1645. https://doi.org/10.1016/j.athoracsur.2015.11.024 Ammerman, B. A., Steinberg, L., & McCloskey, M. S. (2018). Risk-Taking Behavior and Suicidality: The Unique Role of Adolescent Drug Use. Journal of Clinical Child & Adolescent Psychology, 47(1), 131â141. https://doi.org/10.1080/15374416.2016.1220313 Andover, M. S., Pepper, C. M., & Gibb, B. E. (2007). Self-Mutilation and Coping Strategies in a College Sample. Suicide and Life-Threatening Behavior, 37(2), 238â243. https://doi.org/10.1521/suli.2007.37.2.238 Anestis, M. D., Law, K. C., Jin, H., Houtsma, C., Khazem, L. R., & Assavedo, B. L. (2017). Treating the Capability for Suicide: A Vital and Understudied Frontier in Suicide 153 Prevention. Suicide and Life-Threatening Behavior, 47(5), 523â537. https://doi.org/10.1111/sltb.12311 Bakhiyi, C. L., Calati, R., Guillaume, S., & Courtet, P. (2016). Do reasons for living protect against suicidal thoughts and behaviors? A systematic review of the literature. Journal of Psychiatric Research, 77, 92â108. https://doi.org/10.1016/j.jpsychires.2016.02.019 Barnicot, K., & Crawford, M. (2019). Dialectical behaviour therapy v mentalisation-based therapy for borderline personality disorder. Psychological Medicine, 49(12), 2060â2068. psyh. https://doi.org/10.1017/S0033291718002878 Batchelor, R., & Taylor, M. D. (2021). Young adults with epilepsy: Relationships between psychosocial variables and anxiety, depression, and suicidality. Epilepsy & Behavior, 118, 107911. https://doi.org/10.1016/j.yebeh.2021.107911 Batterham, P. J., Ftanou, M., Pirkis, J., Brewer, J. L., Mackinnon, A. J., Beautrais, A., Fairweather-Schmidt, A. K., & Christensen, H. (2015). A systematic review and evaluation of measures for suicidal ideation and behaviors in population-based research. Psychological Assessment, 27(2), 501â512. https://doi.org/10.1037/pas0000053 Batterham, P. J., Gendi, M., Calear, A. L., Shand, F., Sunderland, M., Borschmann, R., OâDea, B., Butterworth, P., Larsen, M., Heffernan, C., Kazan, D., Werner-Seidler, A., Hielscher, E., Han, J., Leach, L., & Farrer, L. M. (2025). The LifeTrack Project: Baseline cohort characteristics and psychosocial factors associated with duration of suicidal ideation and prior suicide attempt. Psychiatry Research Communications, 5(2), 100210. https://doi.org/10.1016/j.psycom.2025.100210 154 Baumel, A., Muench, F., Edan, S., & Kane, J. M. (2019). Objective User Engagement With Mental Health Apps: Systematic Search and Panel-Based Usage Analysis (Preprint). https://doi.org/10.2196/preprints.14567 Beck, A., & Steer, R. (1991). Manual for Beck Scale for Suicide Ideation. San Antonio, TX: Psychological Corporation. Beck, A. T., Brown, G. K., & Steer, R. A. (1997). Psychometric characteristics of the Scale for Suicide Ideation with psychiatric outpatients. Behaviour Research and Therapy, 35(11), 1039â1046. https://doi.org/10.1016/S0005-7967(97)00073-9 Beck, A. T., Kovacs, M., & Weissman, A. (1979). Assessment of suicidal intention: The Scale for Suicide Ideation. Journal of Consulting and Clinical Psychology, 47(2), 343â352. https://doi.org/10.1037/0022-006X.47.2.343 Beck, J.S. (2020). Cognitive behavior therapy: Basics and beyond, 3rd ed. (3rd ed.). Benatov, J., Klomek, A. B., Shira, B., Apter, A., Carli, V., Wasserman, C., Hoven, C. W., Sarchiapone, M., Balazs, J., Bobes, J., Brunner, R., Corcoran, P., Cosman, D., Haring, C., Kahn, J.-P., Keeley, H., Kereszteny, A., Podlogar, T., Postuvan, V., â¦ Wasserman, D. (2020). Doing Nothing is Sometimes Worse: Comparing Avoidant versus Approach Coping Strategies with Peer Victimization and Their Association to Depression and Suicide Ideation. Journal of School Violence, 19(4), 456â469. https://doi.org/10.1080/15388220.2020.1738941 Bennett, D. A. (2001). How can I deal with missing data in my study? Australian and New Zealand Journal of Public Health, 25(5), 464â469. https://doi.org/10.1111/j.1467-842X.2001.tb00294.x 155 Bollen, K., & Lennox, R. (1991). Conventional wisdom on measurement: A structural equation perspective. Psychological Bulletin, 110(2), 305â314. https://doi.org/10.1037/0033-2909.110.2.305 Bonanno, G. A., & Burton, C. L. (2013). Regulatory Flexibility: An Individual Differences Perspective on Coping and Emotion Regulation. Perspectives on Psychological Science, 8(6), 591â612. https://doi.org/10.1177/1745691613504116 Brener, N. D., Kann, Laura, McManus, Tim, Kinchen, Steven, Sundberg, Elizabeth, & Ross, James. (2002). Reliability of the 1999 Youth Risk Behavior Survey Questionnaire. 31(4). Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Cognitive Therapy for the Prevention of Suicide Attempts: A Randomized Controlled Trial. JAMA, 294(5), 563. https://doi.org/10.1001/jama.294.5.563 Bryan, C. J. (2011). The clinical utility of a brief measure of perceived burdensomeness and thwarted belongingness for the detection of suicidal military personnel. Journal of Clinical Psychology, 67(10), 981â992. https://doi.org/10.1002/jclp.20726 Bujang, M. A., Omar, E. D., & Baharum, N. A. (2018). A Review on Sample Size Determination for Cronbachâs Alpha Test: A Simple Guide for Researchers. Malaysian Journal of Medical Sciences, 25(6), 85â99. https://doi.org/10.21315/mjms2018.25.6.9 Canadian Association for Suicide Prevention. (2022). Resources. https://suicideprevention.ca/need-help/ Carver, C. S. (1997). You Want to Measure Coping But Your Protocolâs Too Long: Consider the Brief COPE. Carver, C. S., & Connor-Smith, J. (2010). Personality and Coping. Annual Review of Psychology, 61(1), 679â704. https://doi.org/10.1146/annurev.psych.093008.100352 156 Carver, C. S., Weintraub, J. K., & Scheier, M. F. (1989). Assessing Coping Strategies: A Theoretically Based Approach. Center for Disease Control and Prevention (CDC). (2024, September). Youth Risk Behavior Surveillance System (YRBSS). https://www.cdc.gov/yrbs/questionnaires/index.html Chang, C. J., Feinstein, B. A., Chu, B. C., & Selby, E. A. (2022). Application of minority stress and the interpersonal theory of suicide in bisexual+ versus gay/lesbian young adults. Suicide and Life-Threatening Behavior, 52(4), 725â739. https://doi.org/10.1111/sltb.12856 Cheng, C., Lau, H.-P. B., & Chan, M.-P. S. (2014). Coping flexibility and psychological adjustment to stressful life changes: A meta-analytic review. Psychological Bulletin, 140(6), 1582â1607. https://doi.org/10.1037/a0037913 Christensen, K., & Victor, S. (in press). Refining measurement of suicide ideation to improve testability of suicide theories. Journal of Psychopathology and Clinical Science. Chu, C., Klein, K. M., Buchman-Schmitt, J. M., Hom, M. A., Hagan, C. R., & Joiner, T. E. (2015). Routinized Assessment of Suicide Risk in Clinical Practice: An Empirically Informed Update: Empirically Informed Suicide Risk Assessment. Journal of Clinical Psychology, 71(12), 1186â1200. https://doi.org/10.1002/jclp.22210 Compas, B. E., Connor-Smith, J. K., Saltzman, H., Thomsen, A. H., & Wadsworth, M. E. (2001). Coping with stress during childhood and adolescence: Problems, progress, and potential in theory and research. Psychological Bulletin, 127(1), 87â127. https://doi.org/10.1037/0033-2909.127.1.87 Compas, B. E., Jaser, S. S., Bettis, A. H., Watson, K. H., Gruhn, M. A., Dunbar, J. P., Williams, E., & Thigpen, J. C. (2017). Coping, emotion regulation, and psychopathology in 157 childhood and adolescence: A meta-analysis and narrative review. Psychological Bulletin, 143(9), 939â991. https://doi.org/10.1037/bul0000110 Cramer, R. J., Braitman, A., Bryson, C. N., Long, M. M., & La Guardia, A. C. (2020). The Brief COPE: Factor Structure and Associations With Self- and Other-Directed Aggression Among Emerging Adults. Evaluation & the Health Professions, 43(2), 120â130. https://doi.org/10.1177/0163278719873698 Czyz, E. K., Horwitz, A. G., Arango, A., Cole-Lewis, Y., Berona, J., & King, C. A. (2016). Coping with suicidal urges among youth seen in a psychiatric emergency department. Psychiatry Research, 241, 175â181. https://doi.org/10.1016/j.psychres.2016.04.118 Czyz, E. K., King, C. A., Prouty, D., Micol, V. J., Walton, M., & NahumâShani, I. (2021). Adaptive intervention for prevention of adolescent suicidal behavior after hospitalization: A pilot sequential multiple assignment randomized trial. Journal of Child Psychology and Psychiatry, 62(8), 1019â1031. https://doi.org/10.1111/jcpp.13383 Daglas, Z., Lu, S., Gresham, D., Tatnell, R., Stanley, B. H., & Melvin, G. A. (2024). Classifying coping strategies from suicide prevention safety plans. Suicide and Life-Threatening Behavior, 54(2), 275â285. https://doi.org/10.1111/sltb.13039 DeCou, C. R., Comtois, K. A., & Landes, S. J. (2019). Dialectical Behavior Therapy Is Effective for the Treatment of Suicidal Behavior: A Meta-Analysis. Behavior Therapy, 50(1), 60â72. https://doi.org/10.1016/j.beth.2018.03.009 Dhingra, K., Klonsky, E. D., & Tapola, V. (2019). An Empirical Test of the ThreeâStep Theory of Suicide in U.K. University Students. Suicide and Life-Threatening Behavior, 49(2), 478â487. https://doi.org/10.1111/sltb.12437 158 Durkheim, E. (1897). Suicide, a study in sociology (1951 Edition, J.A. Spaulding, G. Simpson, Trans.). Routledge. Faries, M. D. (2016). Why We Donât âJust Do Itâ: Understanding the Intention-Behavior Gap in Lifestyle Medicine. American Journal of Lifestyle Medicine, 10(5), 322â329. https://doi.org/10.1177/1559827616638017 Faul, F., Erdfelder, E., Buchner, A., & Lang, A.-G. (2009). Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods, 41(4), 1149â1160. https://doi.org/10.3758/BRM.41.4.1149 Field, A. (2013). Discovering Statistics using SPSS (4th ed.). SAGE. Fox, K. R., Huang, X., Guzmán, E. M., Funsch, K. M., Cha, C. B., Ribeiro, J. D., & Franklin, J. C. (2020). Interventions for suicide and self-injury: A meta-analysis of randomized controlled trials across nearly 50 years of research. Psychological Bulletin, 146(12), 1117â1145. https://doi.org/10.1037/bul0000305 Glatt, S., Greene, A. L., & Goodman, M. (2025). WithinâPerson Relationships Between Perceived SuicideâRelated Coping and Suicide Risk and Protective Factors in HighâRisk Veterans With Borderline Personality Disorder Symptoms. Suicide and Life-Threatening Behavior, 55(3), e70024. https://doi.org/10.1111/sltb.70024 Gonzalez, V. M. (2019). Factors linking suicidal ideation with drinking to cope and alcohol problems in emerging adult college drinkers. Experimental and Clinical Psychopharmacology, 27(2), 166â177. https://doi.org/10.1037/pha0000242 Gordon, K. (2021). The Suicidal Thoughts Workbook: CBT Skills to reduce emotional pain, increase hope, and prevent suicide. New Harbinger Publications. 159 Gould, M. S., Chowdhury, S., Lake, A. M., Galfalvy, H., Kleinman, M., Kuchuk, M., & McKeon, R. (2021). National Suicide Prevention Lifeline crisis chat interventions: Evaluation of chattersâ perceptions of effectiveness. Suicide and Life-Threatening Behavior, 51(6), 1126â1137. https://doi.org/10.1111/sltb.12795 Greenland, S., Senn, S. J., Rothman, K. J., Carlin, J. B., Poole, C., Goodman, S. N., & Altman, D. G. (2016). Statistical tests, P values, confidence intervals, and power: A guide to misinterpretations. European Journal of Epidemiology, 31(4), 337â350. https://doi.org/10.1007/s10654-016-0149-3 Gross, J. J. (1998). The Emerging Field of Emotion Regulation: An Integrative Review. Emotion Regulation, 29. Guerreiro, D. F., Cruz, D., Frasquilho, D., Santos, J. C., Figueira, M. L., & Sampaio, D. (2013). Association Between Deliberate Self-Harm and Coping in Adolescents: A Critical Review of the Last 10 Yearsâ Literature. Archives of Suicide Research, 17(2), 91â105. https://doi.org/10.1080/13811118.2013.776439 Gutiérrez, F., Peri, J. M., Torres, X., Caseras, X., & Valdés, M. (2007). Three dimensions of coping and a look at their evolutionary origin. Journal of Research in Personality, 41(5), 1032â1053. https://doi.org/10.1016/j.jrp.2007.01.006 Hamaker, E. L., Kuiper, R. M., & Grasman, R. P. P. P. (2015). A critique of the cross-lagged panel model. Psychological Methods, 20(1), 102â116. https://doi.org/10.1037/a0038889 Hamza, C. A., Stewart, S. L., & Willoughby, T. (2012). Examining the link between nonsuicidal self-injury and suicidal behavior: A review of the literature and an integrated model. Clinical Psychology Review, 32(6), 482â495. https://doi.org/10.1016/j.cpr.2012.05.003 160 Hayes, S., Strosahl, K., & Wilson, K. (2011). Acceptance and commitment therapy: The process and practice of mindful change. Guildford press. Heffer, T., & Willoughby, T. (2017). A count of coping strategies: A longitudinal study investigating an alternative method to understanding coping and adjustment. PLOS ONE, 12(10), e0186057. https://doi.org/10.1371/journal.pone.0186057 Herzog, S., Choo, T.-H., Galfalvy, H., Mann, J. J., & Stanley, B. H. (2022). Effect of non-suicidal self-injury on suicidal ideation: Real-time monitoring study. The British Journal of Psychiatry, 221(2), 485â487. https://doi.org/10.1192/bjp.2021.225 Hoffberg, A. S., Stearns-Yoder, K. A., & Brenner, L. A. (2020). The Effectiveness of Crisis Line Services: A Systematic Review. Frontiers in Public Health, 7, 399. https://doi.org/10.3389/fpubh.2019.00399 Holden, R. R., Mehta, K., Cunningham, E. J., & McLeod, L. D. (2001). Development and preliminary validation of a scale of psychache. Canadian Journal of Behavioural Science / Revue Canadienne Des Sciences Du Comportement, 33(4), 224â232. https://doi.org/10.1037/h0087144 Hom, M. A., Stanley, I. H., & Joiner, T. E. (2015). Evaluating factors and interventions that influence help-seeking and mental health service utilization among suicidal individuals: A review of the literature. Clinical Psychology Review, 40, 28â39. https://doi.org/10.1016/j.cpr.2015.05.006 Horwitz, A. G., Czyz, E. K., Berona, J., & King, C. A. (2018). Prospective Associations of Coping Styles With Depression and Suicide Risk Among Psychiatric Emergency Patients. Behavior Therapy, 49(2), 225â236. https://doi.org/10.1016/j.beth.2017.07.010 161 Horwitz, A. G., Hill, R. M., & King, C. A. (2011). Specific coping behaviors in relation to adolescent depression and suicidal ideation. Journal of Adolescence, 34(5), 1077â1085. https://doi.org/10.1016/j.adolescence.2010.10.004 Interian, A., Chesin, M., Kline, A., St. Hill, L., King, A., Miller, R., Latorre, M., Gara, M., & Stanley, B. (2021). Coping with Suicidal Urges: An Important Factor for Suicide Risk Assessment and Intervention. Archives of Suicide Research, 25(2), 224â237. https://doi.org/10.1080/13811118.2019.1678538 Jakobsen, J. C., Gluud, C., Wetterslev, J., & Winkel, P. (2017). When and how should multiple imputation be used for handling missing data in randomised clinical trials â a practical guide with flowcharts. BMC Medical Research Methodology, 17(1), 162. https://doi.org/10.1186/s12874-017-0442-1 Jha, S., Jewer, S., Agyapong, V. I. O., & Orji, R. (2025). Can Your Smartphone Save A Life? A Systematic Review of Mobile-Based Interventions For Suicide Prevention. International Journal of HumanâComputer Interaction, 41(1), 723â741. https://doi.org/10.1080/10447318.2024.2323274 Jin, H. M., Khazem, L. R., & Anestis, M. D. (2016). Recent Advances in Means Safety as a Suicide Prevention Strategy. Current Psychiatry Reports, 18(10), 96. https://doi.org/10.1007/s11920-016-0731-0 Joiner, T. E., Robison, M., McClanahan, S., Riddle, M., Manwaring, J., Rienecke, R. D., Le Grange, D., Duffy, A., Mehler, P. S., & Blalock, D. V. (2022). Eating disorder behaviors as predictors of suicidal ideation among people with an eating disorder. International Journal of Eating Disorders, 55(10), 1352â1360. https://doi.org/10.1002/eat.23770 162 Jones, L. B., Vereschagin, M., Wang, A. Y., Munthali, R. J., Pei, J., Richardson, C. G., Halli, P., Xie, H., Rush, B., Yatham, L., Gadermann, A. M., Pendakur, K., Prescivalli, A. P., Munro, L., Bruffaerts, R., Auerbach, R. P., Mortier, P., & Vigo, D. V. (2023). Suicidal Ideation Amongst University Students During the COVID-19 Pandemic: Time Trends and Risk Factors. The Canadian Journal of Psychiatry, 68(7), 531â546. https://doi.org/10.1177/07067437221140375 Kato, T. (2015). Frequently Used Coping Scales: A Meta-Analysis: Frequently Used Coping Scales. Stress and Health, 31(4), 315â323. https://doi.org/10.1002/smi.2557 Kiluk, B. D., Nich, C., Babuscio, T., & Carroll, K. M. (2010). Quality versus quantity: Acquisition of coping skills following computerized cognitive-behavioral therapy for substance use disorders: Quality versus quantity of coping skills. Addiction, 105(12), 2120â2127. https://doi.org/10.1111/j.1360-0443.2010.03076.x Kleiman, E. M., & Liu, R. T. (2013). Social support as a protective factor in suicide: Findings from two nationally representative samples. Journal of Affective Disorders, 150(2), 540â545. https://doi.org/10.1016/j.jad.2013.01.033 Kleiman, E. M., Turner, B. J., Fedor, S., Beale, E. E., Picard, R. W., Huffman, J. C., & Nock, M. K. (2018). Digital phenotyping of suicidal thoughts. Depression and Anxiety, 35(7), 601â608. https://doi.org/10.1002/da.22730 Kline, R. B. (2015). Principles and practice of structural equation modeling. Guilford publications. Klonsky, E. D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27(2), 226â239. psyh. https://doi.org/10.1016/j.cpr.2006.08.002 163 Klonsky, E. D. (2025). How to Produce, Identify, and Motivate Robust Psychological Science: A Roadmap and a Response to Vize et al. Assessment, 32(2), 244â252. https://doi.org/10.1177/10731911241299723 Klonsky, E. D., & Glenn, C. R. (2008). Resisting Urges to Self-Injure. Behavioural and Cognitive Psychotherapy, 36(2), 211â220. https://doi.org/10.1017/S1352465808004128 Klonsky, E. D., Glenn, C. R., Styer, D. M., Olino, T. M., & Washburn, J. J. (2015). The functions of nonsuicidal self-injury: Converging evidence for a two-factor structure. Child and Adolescent Psychiatry and Mental Health, 9. psyh. https://search.ebscohost.com/login.aspx?direct=true&AuthType=shib&db=psyh&AN=2015-44985-001&site=ehost-live&scope=site&custid=s5672194 Klonsky, E. D., Pachkowski, M. C., Shahnaz, A., & May, A. M. (2021). The three-step theory of suicide: Description, evidence, and some useful points of clarification. Preventive Medicine, 152, 106549. https://doi.org/10.1016/j.ypmed.2021.106549 Kolbe, L. J., Kann, L., & Collins, J. L. (1993). The Youth Risk Behavior Surveillance System. Kroenke, K., Spitzer, R. L., Williams, J. B. W., & Lowe, B. (2009). An Ultra-Brief Screening Scale for Anxiety and Depression: The PHQ-4. Kuehn, K. S., Foster, K. T., Czyz, E. K., & King, C. A. (2022). Identifying personâspecific coping responses to suicidal urges: A case series analysis and illustration of the idiographic method. Suicide and Life-Threatening Behavior, 52(3), 490â499. https://doi.org/10.1111/sltb.12841 Kyriazos, T. A. (2018). Applied Psychometrics: Sample Size and Sample Power Considerations in Factor Analysis (EFA, CFA) and SEM in General. Psychology, 09(08), 2207â2230. https://doi.org/10.4236/psych.2018.98126 164 Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer. Lazarus, R. S., & Folkman, S. (1987). Transactional theory and research on emotions and coping. European Journal of Personality, 1(3), 141â169. https://doi.org/10.1002/per.2410010304 Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New Yorkâ¯: Guilford Press. Linehan, M. M. (2015). DBT skills training manual (2nd ed.). The Guilford Press. Linehan, M. M., Comtois, K. A., Brown, M. Z., Heard, H. L., & Wagner, A. (2006). Suicide Attempt Self-Injury Interview (SASII): Development, reliability, and validity of a scale to assess suicide attempts and intentional self-injury. Psychological Assessment, 18(3), 303â312. https://doi.org/10.1037/1040-3590.18.3.303 Linehan, M. M., & Goodstein, J. L. (1983). Reasons for Staying Alive When You Are Thinking of Killing Yourself: The Reasons for Living Inventory. 11. Löwe, B., Wahl, I., Rose, M., Spitzer, C., Glaesmer, H., Wingenfeld, K., Schneider, A., & Brähler, E. (2010). A 4-item measure of depression and anxiety: Validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. Journal of Affective Disorders, 122(1â2), 86â95. https://doi.org/10.1016/j.jad.2009.06.019 Lyne, K., & Roger, D. (2000). A psychometric re-assessment of the COPE questionnaire. Personality and Individual Differences, 29(2), 321â335. https://doi.org/10.1016/S0191-8869(99)00196-8 Marchionatti, L. E., Amaral, R. R., Barcellos, C., Duarte, S., Campello, A. C., Virtuoso, E., & Magalhães, P. V. D. S. (2024). âI donât wanna die, but my brain insists that I shouldâ: A 165 big qualitative data approach to the lived experiences of suicidal thoughts. Frontiers in Psychology, 15, 1420287. https://doi.org/10.3389/fpsyg.2024.1420287 Marty, M. A., Segal, D. L., & Coolidge, F. L. (2010). Relationships among dispositional coping strategies, suicidal ideation, and protective factors against suicide in older adults. Aging & Mental Health, 14(8), 1015â1023. https://doi.org/10.1080/13607863.2010.501068 Marusic, A., & Goodwin, R. D. (2006). Suicidal and Deliberate Self-Harm Ideation Among Patients with Physical Illness: The Role of Coping Styles. Suicide and Life-Threatening Behavior, 36(3), 323â328. https://doi.org/10.1521/suli.2006.36.3.323 May, A., & Klonsky, E. D. (2011). Validity of Suicidality Items From the Youth Risk Behavior Survey in a High School Sample. Assessment, 18(3), 379â381. https://doi.org/10.1177/1073191110374285 McShane, B. B., Gal, D., Gelman, A., Robert, C., & Tackett, J. L. (2019). Abandon Statistical Significance. The American Statistician, 73(sup1), 235â245. https://doi.org/10.1080/00031305.2018.1527253 Melvin, G. A., Gresham, D., Beaton, S., Coles, J., Tonge, B. J., Gordon, M. S., & Stanley, B. (2019). Evaluating the Feasibility and Effectiveness of an Australian Safety Planning Smartphone Application: A Pilot Study Within a Tertiary Mental Health Service. Suicide and Life-Threatening Behavior, 49(3), 846â858. https://doi.org/10.1111/sltb.12490 Micol, V. J., Prouty, D., & Czyz, E. K. (2022). Enhancing motivation and self-efficacy for safety plan use: Incorporating motivational interviewing strategies in a brief safety planning intervention for adolescents at risk for suicide. Psychotherapy, 59(2), 174â180. https://doi.org/10.1037/pst0000374 166 Mishara, B. L., Daigle, M., Bardon, C., Chagnon, F., Balan, B., Raymond, S., & Campbell, J. (2016). Comparison of the Effects of Telephone Suicide Prevention Help by Volunteers and Professional Paid Staff: Results from Studies in the USA and Q uebec, C anada. Suicide and Life-Threatening Behavior, 46(5), 577â587. https://doi.org/10.1111/sltb.12238 Mortier, P., Cuijpers, P., Kiekens, G., Auerbach, R. P., Demyttenaere, K., Green, J. G., Kessler, R. C., Nock, M. K., & Bruffaerts, R. (2018). The prevalence of suicidal thoughts and behaviours among college students: A meta-analysis. Psychological Medicine, 48(4), 554â565. https://doi.org/10.1017/S0033291717002215 Moshagen, M., & Bader, M. (2023). semPower: General Power Analysis for Structural Equation Models. Behavior Research Methods, 56, 2901â2922. Motillon-Toudic, C., Walter, M., Séguin, M., Carrier, J.-D., Berrouiguet, S., & Lemey, C. (2022). Social isolation and suicide risk: Literature review and perspectives. European Psychiatry, 65(1), e65. https://doi.org/10.1192/j.eurpsy.2022.2320 Mou, D., Kleiman, E. M., Fedor, S., Beck, S., Huffman, J. C., & Nock, M. K. (2018). Negative affect is more strongly associated with suicidal thinking among suicidal patients with borderline personality disorder than those without. Journal of Psychiatric Research, 104, 198â201. https://doi.org/10.1016/j.jpsychires.2018.08.006 Muthén, L. K., & Muthén, B. O. (1998). Mplus Userâs Guide (8th ed.). Muthén & Muthén. Na, P. J., Shin, J., Kwak, H. R., Lee, J., Jester, D. J., Bandara, P., Kim, J. Y., Moutier, C. Y., Pietrzak, R. H., Oquendo, M. A., & Jeste, D. V. (2025). Social Determinants of Health and Suicide-Related Outcomes: A Review of Meta-Analyses. JAMA Psychiatry, 82(4), 337. https://doi.org/10.1001/jamapsychiatry.2024.4241 167 National Institute for Health and Care Excellence (NICE). (2022, September 7). Self-harm: Assessment, management and preventing recurrence. https://www.nice.org.uk/guidance/ng225/chapter/Recommendations#interventions-for-self-harm Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M. (2010). Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behaviour Research and Therapy, 48(9), 832â839. https://doi.org/10.1016/j.brat.2010.05.017 Nock, M. K., Holmberg, E. B., Photos, V. I., & Michel, B. D. (2007). Self-Injurious Thoughts and Behaviors Interview: Development, reliability, and validity in an adolescent sample. Psychological Assessment, 19(3), 309â317. https://doi.org/10.1037/1040-3590.19.3.309 Nock, M. K., Millner, A. J., Joiner, T. E., Gutierrez, P. M., Han, G., Hwang, I., King, A., Naifeh, J. A., Sampson, N. A., Zaslavsky, A. M., Stein, M. B., Ursano, R. J., & Kessler, R. C. (2018). Risk factors for the transition from suicide ideation to suicide attempt: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Journal of Abnormal Psychology, 127(2), 139â149. https://doi.org/10.1037/abn0000317 Nuij, C., Van Ballegooijen, W., De Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., OâConnor, R. C., Smit, J. H., Kerkhof, A., & Riper, H. (2021). Safety planning-type interventions for suicide prevention: Meta-analysis. The British Journal of Psychiatry, 219(2), 419â426. https://doi.org/10.1192/bjp.2021.50 Nuijten, M. B. (2022). Assessing and Improving Robustness of Psychological Research Findings in Four Steps. In Avoiding questionable research practices in applied psychology (pp. 379â400). CHAM: Springer International Publishing. 168 Oakey-Frost, N., Moscardini, E. H., Cowan, T., Cohen, A., & Tucker, R. P. (2023). The Temporal Dynamics of Wish to Live, Wish to Die, and Their Short-Term Prospective Relationships With Suicidal Desire. Behavior Therapy, S0005789422001617. https://doi.org/10.1016/j.beth.2022.12.011 Olsson-Collentine, A., Van Aert, R. C. M., Bakker, M., & Wicherts, J. (2023). Meta-analyzing the multiverse: A peek under the hood of selective reporting. Psychological Methods. https://doi.org/10.1037/met0000559 Orth, U., Clark, D. A., Donnellan, M. B., & Robins, R. W. (2021). Testing prospective effects in longitudinal research: Comparing seven competing cross-lagged models. Journal of Personality and Social Psychology, 120(4), 1013â1034. https://doi.org/10.1037/pspp0000358 Orth, U., Meier, L. L., Bühler, J. L., Dapp, L. C., Krauss, S., Messerli, D., & Robins, R. W. (2024). Effect size guidelines for cross-lagged effects. Psychological Methods, 29(2), 421â433. https://doi.org/10.1037/met0000499 Otten, D., Ernst, M., Tibubos, A. N., Brähler, E., Fleischer, T., Schomerus, G., Wild, P. S., Zöller, D., Binder, H., Kruse, J., Johar, H., Atasoy, S., Grabe, H. J., Ladwig, K.-H., Münzel, T., Völzke, H., König, J., & Beutel, M. E. (2022). Does social support prevent suicidal ideation in women and men? Gender-sensitive analyses of an important protective factor within prospective community cohorts. Journal of Affective Disorders, 306, 157â166. https://doi.org/10.1016/j.jad.2022.03.031 Pachkowski, M. C., May, A. M., Tsai, M., & Klonsky, E. D. (2019). A Brief Measure of Unbearable Psychache. Suicide and Life-Threatening Behavior, 49(6), 1721â1734. https://doi.org/10.1111/sltb.12556 169 Palan, S., & Schitter, C. (2018). Prolific.acâA subject pool for online experiments. Journal of Behavioral and Experimental Finance, 17, 22â27. https://doi.org/10.1016/j.jbef.2017.12.004 Paulhus, D. L., & Vazire, S. (2007). The self-report method. In Handbook of research methods in personality psychology (pp. 224â239). Peele, S., & Brodsky, A. (2000). Exploring psychological benefits associated with moderate alcohol use: A necessary corrective to assessments of drinking outcomes? Drug and Alcohol Dependence, 60(3), 221â247. https://doi.org/10.1016/S0376-8716(00)00112-5 Pettit, J. W., Temple, S. R., Norton, P. J., Yaroslavsky, I., Grover, K. E., Morgan, S. T., & Schatte, D. J. (2009). Thought suppression and suicidal ideation: Preliminary evidence in support of a robust association. Depression and Anxiety, 26(8), 758â763. https://doi.org/10.1002/da.20512 Pienaar, J., Rothmann, S., & van de Vijver, F. J. R. (2007). Occupational Stress, Personality Traits, Coping Strategies, and Suicide Ideation in the South African Police Service. Criminal Justice and Behavior, 34(2), 246â258. https://doi.org/10.1177/0093854806288708 Puccio, F., FullerâTyszkiewicz, M., Youssef, G., Mitchell, S., Byrne, M., Allen, N., & Krug, I. (2017). Longitudinal Biâdirectional Effects of Disordered Eating, Depression and Anxiety. European Eating Disorders Review, 25(5), 351â358. https://doi.org/10.1002/erv.2525 Rainbow, C., Tatnell, R., Blashki, G., & Melvin, G. A. (2023). Revisiting the factor structure of the suicide-related coping scale: Results from two samples of Australian online help-170 seekers. Psychiatry Research, 324, 115195. https://doi.org/10.1016/j.psychres.2023.115195 Ribeiro, J. D., Franklin, J. C., Fox, K. R., Bentley, K. H., Kleiman, E. M., Chang, B. P., & Nock, M. K. (2016). Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: A meta-analysis of longitudinal studies. Psychological Medicine, 46(2), 225â236. https://doi.org/10.1017/S0033291715001804 Richardson, C. E., Magson, N. R., Fardouly, J., Oar, E. L., Forbes, M. K., Johnco, C. J., & Rapee, R. M. (2021). Longitudinal Associations between Coping Strategies and Psychopathology in Pre-adolescence. Journal of Youth and Adolescence, 50(6), 1189â1204. https://doi.org/10.1007/s10964-020-01330-x Rogers, M. L., Gallyer, A. J., & Joiner, T. E. (2021). The relationship between suicide-specific rumination and suicidal intent above and beyond suicidal ideation and other suicide risk factors: A multilevel modeling approach. Journal of Psychiatric Research, 137, 506â513. https://doi.org/10.1016/j.jpsychires.2021.03.031 Rogers, M. L., Law, K. C., Houtsma, C., Tucker, R. P., Anestis, M. D., & Joiner, T. E. (2022). Development and Initial Validation of a Scale Assessing Suicide-Specific Rumination: The Suicide Rumination Scale. Assessment, 29(8), 1777â1794. https://doi.org/10.1177/10731911211033897 Rudd, M. D., & Bryan, C. J. (2022). Finding Effective and Efficient Ways to Integrate Research Advances Into the Clinical Suicide Risk Assessment Interview. Frontiers in Psychiatry, 13, 846244. https://doi.org/10.3389/fpsyt.2022.846244 Schleider, J. L., Dobias, M. L., Mullarkey, M. C., & Ollendick, T. (2021). Retiring, Rethinking, and Reconstructing the Norm of Once-Weekly Psychotherapy. Administration and Policy 171 in Mental Health and Mental Health Services Research, 48(1), 4â8. https://doi.org/10.1007/s10488-020-01090-7 Selby, E. A., Anestis, M. D., & Joiner, T. E. (2007). Daydreaming About Death: Violent Daydreaming as a Form of Emotion Dysregulation in Suicidality. Behavior Modification, 31(6), 867â879. https://doi.org/10.1177/0145445507300874 Sewall, C. J. R., Goldstein, T. R., & Rosen, D. (2021). Objectively measured digital technology use during the COVID-19 pandemic: Impact on depression, anxiety, and suicidal ideation among young adults. Journal of Affective Disorders, 288, 145â147. https://doi.org/10.1016/j.jad.2021.04.008 Shahnaz, A., & Klonsky, E. D. (2021). Clarifying the association of eating disorder features to suicide ideation and attempts. Journal of Clinical Psychology, 77(12), 2965â2977. https://doi.org/10.1002/jclp.23266 Shneidman, E. (1993). Suicide as psychache: A clinical approach to self-destructive behavior. Jason Aronson. Shneidman, E. S. (1996). The suicidal mind. Oxford University Press. Simon, G. E., Specht, C., & Doederlein, A. (2016). Coping With Suicidal Thoughts: A Survey of Personal Experience. Psychiatric Services, 67(9), 1026â1029. https://doi.org/10.1176/appi.ps.201500281 Simons, J. S., & Gaher, R. M. (2005). The Distress Tolerance Scale: Development and Validation of a Self-Report Measure. Motivation and Emotion, 29(2), 83â102. https://doi.org/10.1007/s11031-005-7955-3 172 Skinner, E. A., Edge, K., Altman, J., & Sherwood, H. (2003). Searching for the structure of coping: A review and critique of category systems for classifying ways of coping. Psychological Bulletin, 129(2), 216â269. https://doi.org/10.1037/0033-2909.129.2.216 Skinner, E. A., & Zimmer-Gembeck, M. J. (2007). The Development of Coping. Annual Review of Psychology, 58(1), 119â144. https://doi.org/10.1146/annurev.psych.58.110405.085705 Solberg, M. A., Gridley, M. K., & Peters, R. M. (2022). The Factor Structure of the Brief Cope: A Systematic Review. Western Journal of Nursing Research, 44(6), 612â627. https://doi.org/10.1177/01939459211012044 Southward, M. W., Howard, K. P., & Cheavens, J. S. (2023). Less is more: Decreasing the frequency of maladaptive coping predicts improvements in DBT more consistently than increasing the frequency of adaptive coping. Behaviour Research and Therapy, 163, 104288. https://doi.org/10.1016/j.brat.2023.104288 Speckens, A. E. M., & Hawton, K. (2005). Social Problem Solving in Adolescents with Suicidal Behavior: A Systematic Review. Suicide and Life-Threatening Behavior, 35(4), 365â387. https://doi.org/10.1521/suli.2005.35.4.365 Stanley, B., & Brown, G. K. (2012). Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19(2), 256â264. https://doi.org/10.1016/j.cbpra.2011.01.001 Stanley, B., & Brown, G. K. (2019). The Safety Planning Intervention to reduce suicide risk: Latest advances. 52nd American Association of Suicidology Annual Conference, Denver, CO, US. Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the Safety 173 Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department. JAMA Psychiatry, 75(9), 894. https://doi.org/10.1001/jamapsychiatry.2018.1776 Stanley, B., Green, K. L., Ghahramanlou-Holloway, M., Brenner, L. A., & Brown, G. K. (2017). The construct and measurement of suicide-related coping. Psychiatry Research, 258, 189â193. https://doi.org/10.1016/j.psychres.2017.08.008 Stanley, B., Martínez-Alés, G., Gratch, I., Rizk, M., Galfalvy, H., Choo, T.-H., & Mann, J. J. (2021). Coping strategies that reduce suicidal ideation: An ecological momentary assessment study. Journal of Psychiatric Research, 133, 32â37. https://doi.org/10.1016/j.jpsychires.2020.12.012 Stanton, K., Carpenter, R. W., Nance, M., Sturgeon, T., & Villalongo Andino, M. (2022). A multisample demonstration of using the prolific platform for repeated assessment and psychometric substance use research. Experimental and Clinical Psychopharmacology, 30(4), 432â443. https://doi.org/10.1037/pha0000545 Statistics Canada. (2023). Suicide in Canada: Key statistics. https://www.canada.ca/en/public-health/services/publications/healthy-living/suicide-canada-key-statistics-infographic.html Steegen, S., Tuerlinckx, F., Gelman, A., & Vanpaemel, W. (2016). Increasing Transparency Through a Multiverse Analysis. Perspectives on Psychological Science, 11(5), 702â712. https://doi.org/10.1177/1745691616658637 Stöber, J. (2001). The Social Desirability Scale-17 (SDS-17). European Journal of Psychological Assessment, 17(3), 222â232. https://doi.org/10.1027//1015-5759.17.3.222 Strathman, A., Gleicher, F., Boninger, D. S., & Edwards, C. S. (1994). The Consideration of Future Consequences: Weighing Immediate and Distant Outcomes of Behavior. 174 Streiner, D. L. (2015). Best (but oft-forgotten) practices: The multiple problems of multiplicityâwhether and how to correct for many statistical tests. The American Journal of Clinical Nutrition, 102(4), 721â728. https://doi.org/10.3945/ajcn.115.113548 Suicide Prevention Resource Center. (2021). Stanley-Brown Safety Plan. https://sprc.org/online-library/stanley-brown-safety-plan/ Tavakol, M., & Dennick, R. (2011). Making sense of Cronbachâs alpha. International Journal of Medical Education, 2, 53â55. https://doi.org/10.5116/ijme.4dfb.8dfd The Centre for Addiction and Mental Health (CAMH). (2023). Suicide Risk: Managing Suicidality. https://www.camh.ca/en/professionals/treating-conditions-and-disorders/suicide-risk/suicide---managing-suicidality Tiwari, S. K., & Wang, J. (2008). Ethnic differences in mental health service use among White, Chinese, South Asian and South East Asian populations living in Canada. Social Psychiatry and Psychiatric Epidemiology, 43(11), 866â871. https://doi.org/10.1007/s00127-008-0373-6 Treloar, H., Piasecki, T. M., McCarthy, D. M., Sher, K. J., & Heath, A. C. (2015). Ecological evidence that affect and perceptions of drink effects depend on alcohol expectancies: Affect, perceptions and alcohol expectancies. Addiction, 110(9), 1432â1442. https://doi.org/10.1111/add.12982 Turton, H., Berry, K., Danquah, A., & Pratt, D. (2021). The relationship between emotion dysregulation and suicide ideation and behaviour: A systematic review. Journal of Affective Disorders Reports, 5, 100136. https://doi.org/10.1016/j.jadr.2021.100136 175 Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575â600. https://doi.org/10.1037/a0018697 Van Orden, K. A., Witte, T. K., Gordon, K. H., Bender, T. W., & Joiner, T. E. (2008). Suicidal desire and the capability for suicide: Tests of the interpersonal-psychological theory of suicidal behavior among adults. Journal of Consulting and Clinical Psychology, 76(1), 72â83. https://doi.org/10.1037/0022-006X.76.1.72 Victor, S. E., & Klonsky, E. D. (2016). Validation of a Brief Version of the Difficulties in Emotion Regulation Scale (DERS-18) in Five Samples. Journal of Psychopathology and Behavioral Assessment, 38(4), 582â589. https://doi.org/10.1007/s10862-016-9547-9 Wang, A. W.-T., Cheng, C.-P., Chang, C.-S., Chen, D.-R., Chen, S.-T., Shieh, V., Lo, A., & Hsu, W.-Y. (2018). Does the Factor Structure of the Brief COPE Fit Different Types of Traumatic Events?: A Test of Measurement Invariance. European Journal of Psychological Assessment, 34(3), 162â173. https://doi.org/10.1027/1015-5759/a000321 Wasserstein, R. L., & Lazar, N. A. (2016). The ASA Statement on p -Values: Context, Process, and Purpose. The American Statistician, 70(2), 129â133. https://doi.org/10.1080/00031305.2016.1154108 Wonderlich, J. A., Crosby, R. D., Engel, S. G., Crow, S. J., Peterson, C. B., Le Grange, D., Wonderlich, S. A., & Fischer, S. (2022). Negative affect and binge eating: Assessing the unique trajectories of negative affect before and after BINGE â EATING episodes across eating disorder diagnostic classifications. International Journal of Eating Disorders, 55(2), 223â230. https://doi.org/10.1002/eat.23648 176 World Health Organization (WHO). (2025). Suicide. In World Health Organization, Geneva. https://www.who.int/news-room/fact-sheets/detail/suicide Zhang, X., & Wu, L.-T. (2014). Suicidal ideation and substance use among adolescents and young adults: A bidirectional relation? Drug and Alcohol Dependence, 142, 63â73. https://doi.org/10.1016/j.drugalcdep.2014.05.025 Zimmer-Gembeck, M. J., & Skinner, E. A. (2016). The Development of Coping: Implications for Psychopathology and Resilience. In D. Cicchetti (Ed.), Developmental Psychopathology (pp. 1â61). John Wiley & Sons, Inc. https://doi.org/10.1002/9781119125556.devpsy410 Zortea, T. C., Gray, C. M., & OâConnor, R. C. (2020). Perceptions of Past Parenting and Adult Attachment as Vulnerability Factors for Suicidal Ideation in the Context of the Integrated MotivationalâVolitional Model of Suicidal Behavior. Suicide and Life-Threatening Behavior, 50(2), 515â533. https://doi.org/10.1111/sltb.12606 177 Appendices Appendix A: Study 1 Semi-Structured Interview of Suicide-Specific Coping âSome people with a history of suicidal thoughts and feelings have made efforts to avoid or reduce the suicidal thoughts and feelings when they occur. This section is concerned with the kinds of methods and techniques that you may have tried. This section is NOT concerned with how you cope when feeling bad, down, or anxious in general. Rather, I am interested in instances when you found yourself feeling suicidal, or considering suicide, but wanted to distract from those thoughts and keep yourself from acting on them. I will read you a list of methods that you may have used to try to avoid or reduce suicidal thoughts or feelings. For each one, you will be asked to indicate how often you have used the method in an attempt to cope with suicidal thoughts using a never, rarely, sometimes, usually, always scale. If it is something you have tried, I will then ask you to indicate the effect it had on your desire to die using the choices increased a lot, increased somewhat, stayed about the same, decreased somewhat, decreased a lot, followed by the effect it had on your desire to live using the choices increased a lot, increased somewhat, stayed about the same, decreased somewhat, decreased a lot, and finally what effect it had on your intent or likelihood that you would make a suicide attempt using the choices increased a lot, increased somewhat, stayed about the same, decreased somewhat, decreased a lot. I will repeat the response choices until you get used to them. Do you have any questions so far? If you have any [other] questions, feel free to ask at any time.â ***Give participant Likert scale paper â explain distinction of B), C) and D)*** Coping Method When you found yourself feeling suicidal, or considering suicide, have you ever triedâ¦ A) How often? 1-Never 2-Rarely 3-Sometimes 4-Usually 5-Always B) What was its effect on your desire to die? 1-increased a lot 2-increased somewhat 3-stayed about the same 4-decreased somewhat 5-decreased a lot C) What was its effect on your desire to live? 1-increased a lot 2-increased somewhat 3-stayed about the same 4-decreased somewhat 5-decreased a lot D) What was its effect on intent/likelihood to make a SA? 1-increased a lot 2-increased somewhat 3-stayed about the same 4-decreased somewhat 5-decreased a lot 1. Talking with a friend or family member and mentioning your suicidal thoughts 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 2. Talking with a friend or family member but not mentioning your suicidal thoughts 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 3. Engaging in a form of self-harm without intending to die (e.g., cutting skin, burning, or hitting) 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 4. Calling a crisis center or help line 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 5. Going to the hospital 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 6. Talking with a therapist or health professional 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 7. Using a pre-established safety plan that you may have developed with a health professional or on your own 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 8. Exercising or engaging in recreational physical activity (e.g., sports, exercise class) 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 9. Watching a movie/TV show/listening to music that is happy 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 10. Watching a movie/TV show/listening to music that is sad 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 178 11. Going to a public place (e.g., coffee shop, park) 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 12. Withdrawing from others and staying alone 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 13. Engaging in meditation or relaxation exercises or mindfulness 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 14. Use sensation to ground (e.g. cold shower, ice, strong smell) 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 15. Finding someone who is understanding 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 16. Using substances (e.g., alcohol, non-prescription drugs) 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 17. Keeping busy (e.g., doing school work, work, cleaning, errands) 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 18. Turning to religion or spirituality 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 19. Thinking about reasons for living or staying alive 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 20. Thinking about good memories 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 21. Thinking about things in the future you are looking forward to 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 22. Being around friends 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 23. Being around people 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 24. Making meaning out of the situation 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 25. Engaging in a positive activity (e.g., hobby, games, spent time outside, etc) 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 26. Playing music (e.g., guitar, piano) 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 27. Anticipating othersâ reactions if you were to act on your suicidal thoughts 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 28. Thinking about others with similar problems 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 29. Going on social media (e.g., Instagram, Facebook, Snapchat, etc) 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 30. Thinking about how painful or how much it would hurt or how scary it would be 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 31. Using an app on your phone designed for coping 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 32. Taking a psychiatric medication 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 33. Taking a hot bath or shower 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 34. Cooking 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 35. Removing the means that could be used from home or reducing ease of access to them 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 36. Going to sleep/taking a nap 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 37. Other (please list): 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Note. Items are summed to create Adaptive (items: 1, 2, 4, 6-9, 11, 13-15, 17-26, 31, 33-36) and Maladaptive (items: 3, 12, 16) scores based on expert clinical judgment (see methods section). 179 Appendix B: Study 2 Self-report Measure of Suicide-Specific Coping Sometimes when people find themselves thinking about or considering suicide, they use coping strategies to deal with their suicidal thoughts. The following questions ask about how frequently you have used these coping strategies in the past week only. These questions are NOT concerned with how you cope feeling down, anxious, or stressed in general. Rather, these questions are specifically asking about how you have coped with your suicidal thoughts this past week. In this past week, when you found yourself thinking about or considering suicide, did you ever: Item Never (1) Rarely (2) Sometimes (3) Usually (4) Always (5) # times /week 1. Socialize with or reach out to a friend or family member and tell them about your suicidal thoughts Never Rarely Sometimes Usually Always #/week 2. Socialize with/reach out to a friend or family member without mentioning your suicidal thoughts Never Rarely Sometimes Usually Always #/week 3. Fantasize about dying/ways to end your life Never Rarely Sometimes Usually Always #/week 4. Contact a crisis center or help line Never Rarely Sometimes Usually Always #/week 5. Think about good memories Never Rarely Sometimes Usually Always #/week 6. Drink alcohol or use recreational drugs Never Rarely Sometimes Usually Always #/week 7. Think about other people with problems that are similar to your own/who are in a similar situation as yourself Never Rarely Sometimes Usually Always #/week 8. Distract yourself by keeping busy Never Rarely Sometimes Usually Always #/week 9. Engage in a positive activity (e.g., hobby, watching a movie/TV, spending time with a pet, reading, playing video games, etc) Never Rarely Sometimes Usually Always #/week 10. Hurt yourself with no intent to end your life (e.g., cutting yourself, burning yourself, hitting yourself, etc) Never Rarely Sometimes Usually Always #/week 11. Think about your reasons for living or your reasons to stay alive Never Rarely Sometimes Usually Always #/week 12. Go to a public place (e.g., coffee shop, park, mall, etc) Never Rarely Sometimes Usually Always #/week 13. Think about how others would react or respond if you were to act on your suicidal thoughts Never Rarely Sometimes Usually Always #/week 14. Engage in mediation or mindfulness exercises (e.g., a breathing exercise, relaxation exercise) Never Rarely Sometimes Usually Always #/week 15. Engage in specific eating behaviours (binging, purging, restriction) Never Rarely Sometimes Usually Always #/week 16. Withdraw from others and stay alone Never Rarely Sometimes Usually Always #/week 17. Think about things in the future you are looking forward to Never Rarely Sometimes Usually Always #/week 18. Go to sleep/take a nap Never Rarely Sometimes Usually Always #/week 19. Take a warm bath or shower Never Rarely Sometimes Usually Always #/week 20. Turn to religion or spirituality Never Rarely Sometimes Usually Always #/week 21. Reduce your access to means/methods that could be used for suicide attempts (i.e., means safety, making your environment safer) Never Rarely Sometimes Usually Always #/week 22. Find a positive meaning, or important âsilver liningâ or perspective, on the situation you are in Never Rarely Sometimes Usually Always #/week 23. Use social media (e.g., Instagram, TikTok, Facebook, Reddit) Never Rarely Sometimes Usually Always #/week 180 24. Listen to sad music or watch a sad movie/tv show Never Rarely Sometimes Usually Always #/week 25. Think about how painful or how much it would hurt or how scary it could be to act on your suicidal thoughts Never Rarely Sometimes Usually Always #/week 26. Ignore or suppress the suicidal thoughts Never Rarely Sometimes Usually Always #/week 27. Use strong sensations (e.g., cold water, ice, strong smells) to âgroundâ yourself and tolerate distress Never Rarely Sometimes Usually Always #/week 28. Engage in risk taking behaviors such as driving too fast, unprotected or aggressive sexual behavior, or putting yourself in situations with unnecessary risk Never Rarely Sometimes Usually Always #/week 29. Talk with a therapist or a health professional Never Rarely Sometimes Usually Always #/week 30. Exercise or engage in recreational physical activity (e.g., go for a run, play sports, go to the gym, attend an exercise class, etc). Never Rarely Sometimes Usually Always #/week 31. Go to the hospital. Never Rarely Sometimes Usually Always #/week 32. Use a pre-established âsafety planâ that you developed with a health professional or on your own Never Rarely Sometimes Usually Always #/week Note. Items are summed to create Adaptive (items: 1, 2, 4, 5, 8, 9, 11, 12, 14, 17-22, 27, 29, 30, 32) and Maladaptive (items: 3, 6, 10, 15, 16, 28) scores based on expert clinical judgment. 181 Appendix C: Rationale for inclusion of suicide-specific coping items in Study 2 Original SSC Interview Item (Study 1) Include? Rationale/Additional notes Final SSC Self-Report item (Study 2) 1. Talking with a friend or family member and mentioning your suicidal thoughts Yes Yes, and keep separate from item 2 due to difference in endorsement and qualitative difference in coping strategy based on findings from Study 1. 1. Socialize with/reach out to a friend or family member and tell them about your suicidal thoughts 2. Talking with a friend or family member but not mentioning your suicidal thoughts Yes See item 1. 2. Socialize with/reach out to a friend or family member but without mentioning your suicidal thoughts 3. Engaging in a form of self-harm without intending to die (e.g., cutting skin, burning, or hitting) Yes Wording clarified. 10. Hurt yourself with no intent to end your life (e.g., cutting yourself, burning yourself, hitting yourself, etc) 4. Calling a crisis center or help line Yes Wording edited to account for text/online chat crisis lines. 4. Contact a crisis center or crisis help line 5. Going to the hospital Yes Included despite low endorsement; 18% used at least once in Study 1. However, clinically important item to include (Chu et al., 2015). 31. Going to the hospital. 6. Talk with a therapist or health professional Yes 29. Talk with a therapist or a health professional 7. Using a pre-established safety plan that you may have developed with a health professional or on your own Yes Included despite low endorsement; 21% used at least once in Study 1. However, clinically important item to include (Chu et al., 2015). Using a pre-established âsafety planâ that you developed with a health professional or on your own 8. Exercising or engaging in recreational physical activity (e.g., sports, exercise class) Yes Examples added. 30. Exercise or engage in recreational physical activity (e.g., go for a run, play sports, go to the gym, attend an exercise class, go for a walk, etc). 9. Watching a movie/TV show/listening to music that is happy No; Combined Similar content to item 25, combined to reduce redundancy (see item 25 below). 10. Watching a movie/TV show/listening to music that is sad Yes Wording simplified to improve clarity. 24. Listen to sad music or watch a sad tv show/movie 11. Going to a public place (e.g., coffee shop, park) Yes Added an additional example. 12. Going to a public place (e.g., coffee shop, park, mall) 12. Withdrawing from others and staying alone Yes 16. Withdraw from others and stayed alone 13. Engaging in meditation or relaxation exercises or mindfulness Yes Wording clarified. 14. Engage in mediation or mindfulness exercises (e.g., a breathing exercise, relaxation exercise) 14. Grounding with strong physical sensations (e.g., using ice, cold shower, strong scents) Yes Wording clarified to align more closely with the TIPP skill from DBT (Linehan, 2015). 27. Use strong sensations (e.g., cold water, ice, strong smells) to âgroundâ yourself and tolerate distress 15. Finding someone who is understanding No Data from Study 1 indicate this item is captured by items 1, 2, and 6 (i.e., friends, family, therapist). Each person who endorsed this item had endorsed 182 1+ of items 1, 2, or 6. Not included to reduce length and redundancy. 16. Using substances (e.g., alcohol, non-prescription drugs) Yes Wording simplified. 6. Drink alcohol or use recreational drugs 17. Keeping busy (e.g., doing school work, work, cleaning, errands) Yes Wording simplified. 8. Distract yourself by keeping busy 18. Turning to religion or spirituality Yes 20. Turn to religion or spirituality 19. Thinking about reasons for living or staying alive Yes Wording clarified. 11. Think about your reasons for living or your reasons to stay alive 20. Thinking about good memories Yes 5. Thinking about good memories 21. Thinking about things in the future you are looking forward to Yes 17. Think about things in the future that you are looking forward to 22. Being around friends No Similar content to items 1 and 2. Not included to reduce length and redundancy. 23. Being around people No Similar content to item 11. Not included to reduce length and redundancy. 24. Making meaning out of the situation Yes Wording clarified. 22. Find a positive meaning or important âsilver liningâ or perspective on the situation you are in 25. Engaging in a positive activity (e.g., hobby, games, time outside, etc) Yes Examples added. 9. Engage in a positive activity (e.g., hobby, watching a movie or TV, reading, playing music, playing with a pet, playing video games) 26. Playing music (e.g., guitar, piano) No; Combined Similar content to item 25, combined to reduce length and redundancy. 27. Anticipating othersâ reactions if you were to act on your suicidal thoughts Yes Wording clarified. 13. Think about how others would react or respond if you were to act on your suicidal thoughts 28. Thinking about others with similar problems Yes Wording clarified. 7. Think about other people with problems that are similar to your own/who are in a similar situation as yourself 29. Going on social media (e.g., Instagram, Facebook, Snapchat, etc) Yes Wording clarified. 23. Use social media (e.g., Instagram, TikTok, Facebook, Reddit) 30. Thinking about how painful or how much it would hurt or how scary it would be Yes Wording clarified. 25. Think about how painful or how much it would hurt or how scary it could be to act on your suicidal thoughts 31. Using an app on your phone designed for coping No Low endorsement; 86% never used in Study 1 32. Taking a psychiatric medication No Low endorsement; 89% never used in Study 1 33. Taking a hot bath or shower Yes Wording clarified. 19. Take a warm bath or shower 34. Cooking No Low endorsement; 87% never used in Study 1. Also similar content to item 25. 35. Removing means that could be used to hurt yourself from home or reducing Yes Wording clarified. Included despite low endorsement; 22% used at least once in 21. Reduce your access to means/methods that could be 183 your ease of access of ways to harm yourself Study 1. However, clinically important item to include (Chu et al., 2015). used for suicide attempts (i.e., means safety, making your environment safer) 36. Going to sleep/taking a nap Yes 18. Go to sleep/take a nap New Item. Item discussed in literature as response to suicidal ideation (Shneidman, 1996) 3. Fantasize about dying/ways to end your life New Item. Item discussed in literature as response to suicidal ideation (Joiner et al., 2022; Shahnaz & Klonsky, 2021) 15. Engage in specific eating behaviours (binging, purging, restriction) New Item. Item discussed in literature as response to suicidal ideation (Pettit et al., 2009) 26. Ignore or suppress the suicidal thoughts New Item. Item discussed in literature as response to suicidal ideation (Ammerman et al., 2018; Nock & Millner et al., 2018). 28. Engage in risk taking behaviors such as driving too fast, unprotected or aggressive sexual behaviors, or putting yourself in situations with unnecessary risk Note. SSC = suicide-specific coping. Details regarding these measures reported in methods section.184 Appendix D: Suicide-Related Coping Scale (SRCS; Stanley et al., 2017) Instructions: Please indicate how strongly you agree or disagree with each of the following statements. If you are not currently suicidal, please answer with reference to when you were most recently suicidal: Strongly Disagree (0) Somewhat Disagree (1) Unsure (2) Somewhat Agree (3) Strongly Agree (4) 1. I have contact information for at least one health care professional (such as a doctor or therapist) whom I can call during a suicidal crisis. 0 1 2 3 4 2. I cannot do anything to control my suicidal thoughts. 0 1 2 3 4 3. I know which friends and/or family members to contact to help take my mind off my suicidal feelings. 0 1 2 3 4 4. I know the nearest hospital or urgent care facility where I can go if I cannot handle my suicidal feelings. 0 1 2 3 4 5. When I feel suicidal, there are places I can go (such as a coffee shop, the gym, place of worship, or shopping mall) to help me take my mind off my problems. 0 1 2 3 4 6. I have several things I can do to get through a suicidal crisis. 0 1 2 3 4 7. I am able to confide in someone, such as a friend, family member, supervisor, or spiritual advisor when I am experiencing a crisis. 0 1 2 3 4 8. Seeking help from health care professionals is a good way to keep myself safe when I am feeling suicidal. 0 1 2 3 4 9. I know it is important to limit access to weapons or other ways to hurt myself when I am feeling suicidal. 0 1 2 3 4 10. Even if I am alone, there are things I can do to take my mind off my suicidal feelings and thoughts for at least a while. 0 1 2 3 4 11. I do not think there is anything that I can do to help myself when I am feeling suicidal. 0 1 2 3 4 12. It is useless to talk to anyone about my suicidal thoughts. 0 1 2 3 4 13. When I am suicidal, I know of things to do by myself that help me feel less suicidal. 0 1 2 3 4 14. I can distract myself by doing other things or thinking about other things when I am feeling suicidal. 0 1 2 3 4 15. If one way of trying to cope with suicidal feelings does not work, I have other ways to try. 0 1 2 3 4 185 16. I am at the mercy of my suicidal thoughts. 0 1 2 3 4 17. I feel that I have no one to turn to when I am feeling suicidal. 0 1 2 3 4 Note. Items 2, 11, 12, 16, and 17 are reverse coded. Sum all 17 items for total score186 Appendix E: Study 2 multiple groups cross-lagged panel model Differences were observed in suicide-specific coping (SSC) across subgroups including sexual orientation, relationship status, highest level of education, annual household income, and psychiatric treatment history. Multiple groups CLPMs were conducted to explore differences in the bidirectional suicide-specific coping and suicidal ideation relationships in these subgroups. As a reminder, power calculations suggested these analyses were underpowered (<40% power) and results should be interpreted with caution. To examine whether cross-lagged effects across groups were meaningfully different, 95% confidence intervals (CI) were examined for each effect. Table D1 reports full results from multiple groups cross-lagged panel model (CLPM) analyses. Regarding sexual orientation, a large positive cross lagged effect of Maladaptive Frequency scale at time 1 predicted suicidal ideation at time 2 for participants with a straight sexual orientation (Ã = .16, p = .001, 95% CI [.08, .24]), whereas a minimal cross lagged effect was observed for participants who had a non-straight sexual orientation (Ã = -.01, p = .86, 95% CI [-.12, .10]). A similar pattern was observed for Maladaptive Variety scale, where a large positive cross lagged effect of Maladaptive Variety at time 1 predicted suicidal ideation at time 2 for participants with a straight sexual orientation (Ã = .12, p = .009, 95% CI [.04, .19]), whereas a minimal cross lagged effect was observed for participants who had a non-straight sexual orientation (Ã = -.002, p = .97, 95% CI [-.10, .10]). Regarding relationship status, a large negative cross lagged effect of Knowledge/Confidence at time 1 predicted suicidal ideation at time 2 for participants who were not currently in a relationship (Ã = -.13, p = .004, 95% CI [-.21, -.06]), whereas a minimal cross 187 lagged effect was observed for participants who were in a relationship (Ã = -.02, p = .77, 95% CI [-.15, .11]); however, 95% CIs for these effects overlapped suggesting this may not be a reliable difference. No other pattern of differences emerged across additional dimensions of coping that these groups differed on. Regarding highest level of education attained, a moderate positive cross lagged effect of Adaptive Frequency scale at time 1 predicted suicidal ideation at time 2 for participants with a Bachelorâs degree or higher (Ã = .09, p = .05, 95% CI [.02, .17]), whereas a minimal cross lagged effect was observed for participants whom had not attained a Bachelorâs degree (Ã = -.02, p = .68, 95% CI [-.11, .07]). A similar pattern was observed for Adaptive Variety scale, where a moderate positive cross lagged effect of Adaptive Variety at time 1 predicted suicidal ideation at time 2 for participants with a Bachelorâs degree or higher (Ã = .10, p = .03, 95% CI [.02, .18]), whereas a minimal cross lagged effect was observed for participants whom had not attained a Bachelorâs degree (Ã = -.02, p = .72, 95% CI [-.11, .07]). A large negative cross lagged effect of Knowledge/Confidence at time 1 predicted suicidal ideation at time 2 for participants with a Bachelorâs degree or higher (Ã = -.15, p = .004, 95% CI [-.24, -.06]), whereas a medium sized and not statistically reliable cross lagged effect was observed for participants whom had not attained a Bachelorâs degree (Ã = -.08, p = .22, 95% CI [-.18, .03]); however, 95% CIs for these effects overlapped suggesting this may not be a reliable difference. Regarding annual household income, a large positive cross lagged effect of Adaptive Frequency at time 1 predicted suicidal ideation at time 2 for participants with an annual income greater than $60,000 (Ã = .14, p = .01, 95% CI [.05, .24]), whereas a minimal cross lagged effect was observed for participants with an annual income less than $60,000 (Ã = -.02, p = .73, 95% CI 188 [-.09, .06]). No other pattern of differences emerged across additional dimensions of coping that these groups differed on. Regarding history of ever receiving psychiatric treatment, a large negative cross lagged effect of Knowledge/Confidence at time 1 predicted suicidal ideation at time 2 for participants who reported no treatment history (Ã = -.21, p = .01, 95% CI [-.35, -.07]), whereas a relatively smaller (albeit, still large) negative cross lagged effect was observed for participants who reported a history of treatment (Ã = -.13, p = .004, 95% CI [-.21, -.06]); however, 95% CIs for these effects overlapped suggesting these effects may not reliably differ. No other pattern of differences emerged across additional dimensions of coping that these groups differed on. Table E1 Multiple groups Cross Lagged Panel Models (CLPM) for dimensions of suicide-specific coping and suicidal ideation exploring demographic and clinical differences Group and SSC dimensions SSC2 ON SSC1 (autoregressive effect) SI2 ON SI1 (autoregressive effect) SI2 ON SSC1 (cross-lagged effect) SSC2 ON SI1 (cross-lagged effect) SSC1 WITH SI1 (correlation) SSC2 WITH SI2 (residual covariance) Sexual Orientation, FreqM Straight .73 (<.001) .66 (<.001) .16 (.001) .02 (.76) .47 (<.001) .38 (<.001) Not Straight .67 (<.001) .76 (<.001) -.01 (.86) .13 (.07) .42 (<.001) .32 (.001) Sexual Orientation, VarM Straight .73 (<.001) .70 (<.001) .12 (.009) .01 (.79) .29 (<.001) .34 (<.001) Not Straight .64 (<.001) .76 (<.001) -.002 (.97) .12 (.12) .24 (.01) .25 (.02) Relationship status, FreqA Single .74 (<.001) .84 (<.001) .02 (.56) .04 (.44) -.25 (<.001) -.03 (.66) In a relationship .85 (<.001) .58 (<.001) .13 (.07) .06 (.24) -.08 (.40) .03 (.81) Relationship status, VarA Single .74 (<.001) .84 (<.001) .03 (.39) .02 (.66) -.19 (.002) .004 (.96) In a relationship .83 (<.001) .57 (<.001) .13 (.07) .06 (.32) -.05 (.59) -.01 (.93) Relationship status, SRCS Single .83 (<.001) .75 (<.001) -.13 (.004) -.04 (.38) -.62 (<.001) -.25 (.001) In a relationship .78 (<.001) .56 (<.001) -.02 (.77) -.03 (.64) -.32 (<.001) -.22 (.03) Education, FreqA Bachelors .83 (<.001) .75 (<.001) .09 (.05) .05 (.24) -.11 (.10) -.02 (.85) No Bachelors .71 (<.001) .74 (<.001) -.02 (.68) .06 (.38) -.26 (.001) -.03 (.75) 189 Education, VarA Bachelors .80 (<.001) .75 (<.001) .10 (.03) .03 (.52) -.09 (.22) -.06 (.51) No Bachelors .73 (<.001) .74 (<.001) -.02 (.72) .07 (.26) -.19 (.01) .04 (.65) Education, SRCS Bachelors .81 (<.001) .67 (<.001) -.15 (.004) -.04 (.40) -.49 (<.001) -.16 (.06) No Bachelors .84 (<.001) .70 (<.001) -.08 (.22) -.02 (.65) -.54 (<.001) -.32 (<.001) Annual Income, FreqA <$60,000 .81 (<.001) .80 (<.001) -.02 (.73) .08 (.10) -.31 (<.001) -.13 (.11) >$60,000 .80 (<.001) .69 (<.001) .14 (.01) .03 (.62) -.06 (.48) .06 (.52) Annual Income, SRCS <$60,000 .79 (<.001) .76 (<.001) -.08 (.16) -.08 (.12) -.64 (<.001) -.25 (.001) >$60,000 .82 (<.001) .64 (<.001) -.11 (.09) -.001 (.99) -.39 (<.001) -.24 (.009) Treatment History, FreqA No treatment .82 (<.001) .70 (<.001) .06 (.38) .03 (.61) -.27 (.003) -.13 (.29) Treatment .80 (<.001) .77 (<.001) .03 (.40) .07 (.11) -.15 (.02) .03 (.68) Treatment History, VarA No treatment .84 (<.001) .70 (<.001) .07 (.31) .02 (.70) -.16 (.08) -.08 (.51) Treatment .77 (<.001) .77 (<.001) .04 (.39) .05 (.26) -.13 (.04) .01 (.86) Treatment History, VarM No treatment .73 (<.001) .67 (<.001) .12 (.09) .04 (.61) .16 (.09) .49 (<.001) Treatment .68 (<.001) .75 (<.001) .04 (.38) .06 (.25) .30 (<.001) .25 (<.001) Treatment History, SRCS No treatment .81 (<.001) .55 (<.001) -.21 (.01) -.03 (.72) -.63 (<.001) -.35 (.001) Treatment .82 (<.001) .70 (<.001) -.13 (.004) -.04 (.36) -.49 (<.001) -.21 (.003) Note. Standardized effects are reported, with p values reported in parentheses. SSC = suicide-specific coping, SI = suicidal ideation (measured using first 7 items of the Beck Scale for Suicidal ideation); FreqM = Frequency of maladaptive suicide-specific coping; VarM = Variety of maladaptive suicide-specific coping; FreqA = Frequency of adaptive suicide-specific coping; VarA = Variety of adaptive suicide-specific coping; SRCS = Knowledge/Confidence suicide-specific coping dimension (measured using the Suicide-Related Coping Scale); Bachelors = attained a Bachelorâs degree or higher. Sample sizes for subgroups are reported in demographics and clinical history tables. 190 Appendix F: Study 2 confidence intervals for cross-lagged panel model analyses To supplement the results reported for research question one in Study 2 in the main document, CLPM analyses results are reported in Table F1 below with the addition of 95% confidence intervals for all cross-lagged effects. Table F1 Cross-Lagged Panel Model (CLPM) results including confidence intervals for all suicide-specific coping dimensions and individual items and suicidal ideation Suicide-specific dimension and individual items in CLPM SSC2 on SSC1 (autoregressive effect) SI2 on SI1 (autoregressive effect) SI2 on SSC1 (cross-lagged effect) SSC2 on SI1 (cross-lagged effect) SSC1 with SI1 (correlation) SSC2 with SI2 (residual covariance) Frequency of Adaptive .81 (<.001) .75 (<.001) .05 [-.02, .12] .06 [-.01, .13] -.17 (.001) -.01 (.92) Frequency of Maladaptive .70 (<.001) .70 (<.001) .09 [.01, .17] .06 [-.02, .15] .45 (<.001) .36 (<.001) Variety of Adaptive .79 (<.001) .75 (<.001) .06 [-.01, .13] .04 [-.03, .11] -.13 (.01) -.01 (.93) Variety of Maladaptive .69 (<.001) .72 (<.001) .07 [-.001, .14] .05 [-.03, .13] .27 (<.001) .31 (<.001) Knowledge/Confidence .82 (<.001) .68 (<.001) -.12 [-.20, -.04] -.03 [-.10, .04] -.52 (<.001) -.24 (<.001) 1. Socialize, mention SI .61 (<.001) .74 (<.001) .02 [-.05, .09] -.01 [-.10, .08] .05 (.36) -.10 (.13) 2. Socialize, do not mention SI .54 (<.001) .74 (<.001) -.01 [-.08, .06] .02 [-.08, .12] -.14 (.006) .01 (.91) 3. Fantasize about dying .45 (<.001) .69 (<.001) .10 [.02, .18] .23 [.13, .33] .52 (<.001) .40 (<.001) 4. Contact crisis center .60 (<.001) .74 (<.001) .03 [-.04, .10] .09 [.004, .18] .07 (.22) -.02 (.79) 5. Think of good memories .63 (<.001) .75 (<.001) .02 [-.06, .09] -.01 [-.10, .08] -.25 (<.001) -.11 (.07) 6. Use substances .70 (<.001) .74 (<.001) .02 [-.05, .09] .03 [-.05, .11] .11 (.03) .17 (.01) 7. Think of others with similar problems .43 (<.001) .74 (<.001) -.004 [-.07, .07] -.01 [-.11, .09] -.08 (.12) .03 (.64) 8. Distract by keeping busy .52 (<.001) .74 (<.001) .01 [-.06, .08] -.02 [-.12, .07] -.13 (.01) .04 (.55) 9. Positive activity .49 (<.001) .76 (<.001) .09 [.02, .16] .07 [-.03, .18] -.21 (<.001) -.13 (.03) 10. NSSI .58 (<.001) .75 (<.001) -.03 [-.10, .04] .04 [-.05, .14] .26 (<.001) .26 (<.001) 11. Think of reasons for living .48 (<.001) .72 (<.001) -.06 [-.13, .02] -.11 [-.22, -.01] -.32 (<.001) .02 (.71) 12. Go to public place .58 (<.001) .74 (<.001) .02 [-.05, .09] -.001 [-.09, .09] -.03 (.53) .10 (.09) 13. Think of how others would react if acted on SI .47 (<.001) .74 (<.001) .001 [-.07, .07] -.05 [-.15, .05] -.11 (.04) .10 (.11) 14. Meditation or mindfulness .49 (<.001) .75 (<.001) .03 [-.04, .10] -.01 [-.11, .09] -.11 (.04) .003 (.96) 15. Eating behaviours (binging, purging, restriction) .63 (<.001) .74 (<.001) .04 [-.03, .11] .13 [.04, .21] .16 (.002) .12 (.05) 16. Withdraw from others .63 (<.001) .73 (<.001) .03 [-.04, .11] .05 [-.04, .15] .32 (<.001) .27 (<.001) 17. Think about things looking forward to .50 (<.001) .75 (<.001) .02 [-.06, .09] -.01 [-.12, .09] -.29 (<.001) -.15 (.02) 18. Sleep/nap .58 (<.001) .74 (<.001) .05 [-.02, .12] .03 [-.06, .12] .10 (.06) -.03 (.54) 19. Warm bath/shower .61 (<.001) .74 (<.001) .03 [-.03, .11] .05 [-.04, .14] .07 (.17) .06 (.32) 20. Religion/spirituality .72 (<.001) .74 (<.001) .04 [-.03, .11] .05 [-.03, .13] -.05 (.35) .08 (.17) 21. Means safety .52 (<.001) .74 (<.001) .07 [-.001, .14] .03 [-.07, .12] .04 (.41) .11 (.07) 22. Find positive meaning .49 (<.001) .74 (<.001) .003 [-.07, .07] -.07 [-.17, .03] -.23 (<.001) .01 (.84) 23. Social media .63 (<.001) .74 (<.001) .01 [-.06, .08] .02 [-.06, .11] .08 (.13) .04 (.49) 191 24. Sad music/movie .55 (<.001) .74 (<.001) .03 [-.04, .10] .05 [-.05, .14] .23 (<.001) .13 (.04) 25. Think of how painful/scary acting on SI would be .56 (<.001) .74 (<.001) .04 [-.03, .11] .05 [-.04, .14] -.03 (.57) .05 (.39) 26. Ignore/supress SI .45 (<.001) .76 (<.001) .05 [-.02, .12] -.12 [-.23, -.02] -.28 (<.001) -.01 (.88) 27. Strong sensations for grounding .52 (<.001) .74 (<.001) .04 [-.03, .11] .02 [-.07, .12] .04 (.40) .16 (.01) 28. Risk taking behaviors .48 (<.001) .72 (<.001) .13 [.06, .20] .08 [-.02, .18] .19 (<.001) .03 (.67) 29. Therapist/health professional .68 (<.001) .74 (<.001) .06 [-.01, .13] .01 [-.07, .10] -.001 (.98) .03 (.61) 30. Exercise .72 (<.001) .74 (<.001) .06 [-.01, .13] .001 [-.08, .08] -.04 (.49) .09 (.15) 31. Go to hospital .80 (<.001) .74 (<.001) .04 [-.03, .11] -.06 [-.13, .01] .10 (.05) .04 (.54) 32. Use Safety Plan .68 (<.001) .74 (<.001) .05 [-.02, .12] .01 [-.07, .10] .02 (.77) .15 (.02) Note. SSC = suicide-specific coping dimension or item; SI = suicidal ideation (measured using first 7 items of the Beck Scale for Suicidal ideation). Knowledge/Confidence in SSC measured using Suicide-Related Coping Scale (Stanley et al., 2017). Subscripts 1 and 2 denote time points 1 and 2. Standardized effects are reported, with 95% confidence intervals (CI) reported in square bracket parentheses for cross-lagged effects, and p values reported in parentheses for remaining effects. Sample size for analyses n=312.
Thesis/Dissertation
eng
Psychology
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Klonsky, E. David
Coping with suicidal ideation : a cross-sectional and longitudinal examination
Text