Nominating primary confidants (i.e., safety plan nominees) is central to safety planning for suicide but there is a dearth of research about such confidants—a serious oversight given their high-leverage position to affect pathways into clinical care. Informed by advance care planning (ACP) work, this study examined differences between social network members who were and were not identified as primary confidants on attributes that could impact their effectiveness in a helping role. Using social network methodology, information was collected from 41 individuals with affective disorders about the 332 people and relationships in their networks. Logistic regression analysis revealed that being perceived as capable of managing stress and prioritizing the participant’s best interests over one’s own increased the odds of being a primary confidant. Clinicians working with suicidal individuals may benefit from integrating ACP principles—which recognize the thoughtful selection of nominees based on specific attributes—into their safety planning procedures.
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Aging with Dignity. (2017). Five wishes. Retrieved July 8, 2017, from http://www.agingwithdignity.org
Baca-Garcia, E., Perez-Rodriguez, M. M., Oquendo, M. A., et al. (2011). Estimating risk for suicide attempt: Are we asking the right questions? Passive suicidal ideation as a marker for suicidal behavior. Journal of Affective Disorders,134(1), 327–332.
Benditt, J. O., Smith, T. S., & Tonelli, M. R. (2001). Empowering the individual with ALS at the end-of-life: Disease-specific advance care planning. Muscle and Nerve,24(12), 1706–1709.
Biegel, D. E., Pernice-Duca, F., Chang, C., et al. (2013). Correlates of peer support in a clubhouse setting. Community Mental Health Journal,49(3), 249–259.
Buckey, J. W., & Abell, N. (2004). Validation of the health care surrogate preferences scale. Social Work,49(3), 432–440.
Buckey, J. W., & Abell, N. (2010). Life-sustaining treatment decisions: A social work response to meet needs of health care surrogates. Journal of Social Work in End-of-Life & Palliative Care,6(1–2), 27–50.
Buckey, J. W., & Molina, O. (2012). Honoring patient care preferences: Surrogates speak. OMEGA-Journal of Death and Dying,65(4), 257–280.
Chaudoir, S. R., & Fisher, J. D. (2010). The disclosure processes model: Understanding disclosure decision making and postdisclosure outcomes among people living with a concealable stigmatized identity. Psychological Bulletin,136(2), 236.
Comer, A. R., Slaven, J. E., Montz, A., Burke, E., Inger, L., & Torke, A. (2018). Nontraditional surrogate decision makers for hospitalized older adults. Medical Care,56(4), 337–340.
Davidson, C. L., Anestis, M. D., & Gutierrez, P. M. (2017). Ecological momentary assessment is a neglected methodology in suicidology. Archives of Suicide Research,21(1), 1–11.
De Luca, S. M., & Wyman, P. A. (2012). Association between school engagement and disclosure of suicidal ideation to adults among Latino adolescents. The Journal of Primary Prevention,33(2–3), 99–110.
Derogatis, L. R. (1993). Brief symptom inventory: BSI. Upper Saddle River: Pearson.
Derogatis, L. R., & Melisaratos, N. (1983). The brief symptom inventory: An introductory report. Psychological Medicine,13(03), 595–605.
Encrenaz, G., Kovess-Masféty, V., Gilbert, F., Galéra, C., Lagarde, E., Mishara, B., & Messiah, A. (2012). Lifetime risk of suicidal behaviors and communication to a health professional about suicidal ideation. Crisis, 33, 127–136.
Fowler, J. C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy,49(1), 81.
Frey, L. M., Fulginiti, A., Lezine, D. (2016). Suicide attempt survivors and individuals with lived experiences: How can we increase the likelihood for disclosure? Presented at the American Association of Suicidology Annual Conference, Chicago, IL. Manuscript currently under review
Frey, L. M., Fulginiti, A., Lezine, D., & Cerel, J. (2018). The decision-making process for disclosing suicidal ideation and behavior to family and friends. Family Relations,67(3), 414–427.
Frey, L. M., Hans, J. D., & Cerel, J. (2017). An interpretive phenomenological inquiry of family and friend reaction to suicide disclosure. Journal of Marital and Family Therapy,43, 159–172. https://doi.org/10.1111/jmft.12180.
Fulginiti, A., Pahwa, R., Frey, L. M., Rice, E., & Brekke, J. (2016). What factors influence the decision to share suicidal thoughts? A multilevel social network analysis of disclosure among individuals with serious mental illness. Suicide and Life-Threatening Behavior,46(4), 398–412.
Garland, A. F., & Zigler, E. (1993). Adolescent suicide prevention: Current research and social policy implications. American Psychology,48, 169–182.
Green, J. D., Kearns, J. C., Rosen, R. C., Keane, T. M., & Marx, B. P. (2017). Evaluating the effectiveness of safety plans for military veterans: Do safety plans tailored to veteran characteristics decrease suicide risk? Behavior Therapy,49, 931–938.
Greene, K., Derlega, V. J., Yep, G. A., & Petronio, S. (2003). Privacy and disclosure of HIV in interpersonal relationships: A sourcebook for researchers and practitioners. Mahwah: Erlbaum.
Gump, B. B., & Kulik, J. A. (1997). Stress, affiliation, and emotional contagion. Journal of Personality and Social Psychology,72(2), 305.
Hill, A. L., Rand, D. G., Nowak, M. A., et al. (2010). Emotions as infectious diseases in a large social network: The SISa model. Proceedings of the Royal Society of London B: Biological Sciences,277(1701), 3827–3835.
Isaac, M., Elias, B., Katz, L. Y., Belik, S. L., Deane, F. P., Enns, M. W.,… & Swampy Cree, Suicide Prevention Team (2009). Gatekeeper training as a preventative intervention for suicide: A systematic review. The Canadian Journal of Psychiatry, 54(4), 260–268
Jobes, D. A. (1995). The challenge and the promise of clinical suicidology. Suicide & Life-Threatening Behavior,25, 437–449.
Jobes, D. A. (2006). Managing suicidal risk: A collaborative approach. New York: Guilford Publications.
Joiner, T. E., Jr., Conwell, Y., Fitzpatrick, K. K., et al. (2005). Four studies on how past and current suicidality relate even when” everything but the kitchen sink” is covaried. Journal of Abnormal Psychology,114(2), 291.
Joiner, T. E., Jr., Van Orden, K. A., Witte, T. K., & Rudd, M. D. (2009). The interpersonal theory of suicide: Guidance for working with suicidal clients. Washington, DC: American Psychological Association.
Jones, S. L., Roth, D., & Jones, P. K. (1995). Effect of demographic and behavioral variables on burden of caregivers of chronic mentally ill persons. Psychiatric Services,46(2), 141–145.
Kalafat, J., & Elias, M. J. (1995). Suicide prevention in an educational context: Broad and narrow foci. Suicide & Life-Threatening Behavior, 25(1), 123–133.
Kelly, A. E. (2002). The psychology of secrets. New York: Kluwer Academic/Plenum.
Kjellin, L., & Östman, M. (2005). Relatives of psychiatric inpatients—Do physical violence and suicide attempts of patients influence family burden and participation in care? Nordic Journal of Psychiatry,59(1), 7–11.
Kleiman, E. M., Turner, B. J., Fedor, S., Beale, E. E., Huffman, J. C., & Nock, M. K. (2017). Examination of real-time fluctuations in suicidal ideation and its risk factors: Results from two ecological momentary assessment studies. Journal of Abnormal Psychology,126(6), 726–738.
Lakeman, R., & Fitzgerald, M. (2009). Ethical suicide research: A survey of researchers. International Journal of Mental Health Nursing,18(1), 10–17.
Latkin, C., Yang, C., Tobin, K., Roebuck, G., Spikes, P., & Patterson, J. (2012). Social network predictors of disclosure of MSM behavior and HIV-positive serostatus among African American MSM in Baltimore, Maryland. AIDS and Behavior,16(3), 535–542.
Li, Z., Page, A., Martin, G., & Taylor, R. (2011). Attributable risk of psychiatric and socio-economic factors for suicide from individual-level, population-based studies: A systematic review. Social Science and Medicine,72(4), 608–616.
Linehan, M. M., Comtois, K. A., & Ward-Ciesielski, E. F. (2012). Assessing and managing risk with suicidal individuals. Cognitive and Behavioral Practice,19(2), 218–232.
Martin, J. S., Ghahramanlou-Holloway, M., Englert, D. R., Bakalar, J. L., Olsen, C., Nademin, E. M.,… & Branlund, S. (2013). Marital status, life stressor precipitants, and communications of distress and suicide intent in a sample of United States Air Force suicide decedents. Archives of Suicide Research, 17(2), 148–160
McDonell, M. G., Short, R. A., Berry, C. M., et al. (2003). Burden in schizophrenia caregivers: Impact of family psychoeducation and awareness of patient suicidality. Family Process,42(1), 91–103.
McPherson, M., Smith-Lovin, L., & Cook, J. M. (2001). Birds of a feather: Homophily in social networks. Annual Review of Sociology,27(1), 415–444.
National Hospice and Palliative Care Organization. (2017). Selecting your healthcare agent. Retrieved July 27, 2017, from http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3286.
Pahwa, R., Fulginiti, A., Brekke, J. S., & Rice, E. (2017). Mental illness disclosure decision making. American Journal of Orthopsychiatry,87(5), 575–584.
Petronio, S. (2002). Boundaries of privacy. Albany: State University of New York Press.
Pompili, M., Gonda, X., Serafini, G., Innamorati, M., Sher, L., Amore, M.,… & Girardi, P. (2013). Epidemiology of suicide in bipolar disorders: A systematic review of the literature. Bipolar Disorders, 15(5), 457–490
Pompili, M., Murri, M. B., Patti, S., et al. (2016). The communication of suicidal intentions: A meta-analysis. Psychological Medicine,46(11), 2239–2253.
Rice, E. (2010). The positive role of social networks and social networking technology in the condom-using behaviors of homeless young people. Public Health Reports,125, 588–595.
Rice, E., Comulada, S., Green, S., Arnold, E. M., & Rotheram-Borus, M. J. (2009). Differential disclosure across social network ties among women living with HIV. AIDS and Behavior,13(6), 1253.
Rogers, M. L., Chu, C., & Joiner, T. (2019). The necessity, validity, and clinical utility of a new diagnostic entity: Acute suicidal affective disturbance. Journal of Clinical Psychology,75(6), 999–1010.
Rosenquist, J. N., Fowler, J. H., & Christakis, N. A. (2011). Social network determinants of depression. Molecular Psychiatry,16(3), 273–281.
Ryan, C. J., Large, M., Gribble, R., et al. (2015). Assessing and managing suicidal patients in the emergency department. Australasian Psychiatry,23, 513–516.
Sherbourne, C. D., & Stewart, A. L. (1991). The MOS social support survey. Social Science and Medicine,32, 705–714.
Singer, P. A., Robertson, G., & Roy, D. J. (1996). Bioethics for clinicians: Advance care planning. CMAJ: Canadian Medical Association Journal,155(12), 1689–1692.
Stanley, B., & Brown, G. K. (2008). Safety planning guide: A quick guide for clinicians. Boulder: Western Interstate Commission for Higher Education. Retrieved January 14, 2018, from http://www.sprc.org/sites/default/files/SafetyPlanningGuide%20Quick%20Guide%20for%20Clinicians.pdf
Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice,19(2), 256–264.
Sudore, R. L., Lum, H. D., You, J. J., Hanson, L. C., Meier, D. E., Pantilat, S. Z.,… & Kutner, J. S. (2017). Defining advance care planning for adults: A consensus definition from a multidisciplinary Delphi panel. Journal of Pain and Symptom Management, 53(5), 821–832
Tidemalm, D., Langstrom, N., Lichtenstein, P., & Runeson, B. (2008). Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long term follow-up. BMJ (Clinical Research Ed.),337, a2205. https://doi.org/10.1136/bmj.a2205.
Tucker, R. P., Michaels, M. S., Rogers, M. L., Wingate, L. R., & Joiner, T. E. (2016). Construct validity of a proposed new diagnostic entity: Acute suicidal affective disturbance (ASAD). Journal of Affective Disorders,189, 365–378. https://doi.org/10.1016/j.jad.2015.07.049.
U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention. (2012). 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC: U.S. Department of Health and Human Services.
Van Heeringen, K., & Bijttebier, S. (2016). A review of neuropsychological studies of suicidal ideation and behavior. In The international handbook of suicide prevention (p. 170).
Vangelisti, A. L., & Caughlin, J. P. (1997). Revealing family secrets: The influence of topic, function, and relationships. Journal of Social and Personal Relationships,14(5), 679–705.
Vangelisti, A. L., Caughlin, J. P., & Timmerman, L. (2001). Criteria for revealing family secrets. Communication Monographs,68, 1–27.
Wendler, D., & Rid, A. (2011). Systematic review: The effect on surrogates of making treatment decisions for others. Annals of Internal Medicine,154(5), 336–346.
Wolk-Wasserman, D. (1986). Suicidal communication of persons attempting suicide and responses of significant others. Acta Psychiatrica Scandinavica,73(5), 481–499.
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Fulginiti, A., Frey, L.M. Are the “Right” People Selected for First Disclosures About Suicidal Thoughts? Exploring What We Know About Advance Care Planning in the Context of Safety Planning. Community Ment Health J 56, 174–185 (2020). https://doi.org/10.1007/s10597-019-00457-x
- Safety planning
- Advance care planning
- Social network
- Suicidal communication