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THE CATHOLIC UNIVERSITY of AMERICA a Cross-Cultural THE CATHOLIC UNIVERSITY OF AMERICA A Cross-Cultural Examination of Suicide Status Form Responses A DISSERTATION Submitted to the Faculty of the Department of Psychology School of Arts and Sciences Of The Catholic University of America In Partial Fulfillment of the Requirements For the Degree Doctor of Philosophy By Blaire C. Schembari Washington, D.C. 2017 A Cross-Cultural Examination of Suicide Status Form Responses Blaire C. Schembari, Ph.D. Director: David A. Jobes, Ph.D. Globally, an estimated 800,000 people die by suicide each year (World Health Organization [WHO], 2014). The epidemiological variations in suicide rates across the world point to the potential role culture plays in the experience of suicidality. Although suicide is widely regarded as a potentially preventable death, meaningfully reducing suicide rates has proven to be a challenge. In direct response to the need to clinically treat suicidal risk, Jobes (2012; 2016) developed a suicide-specific therapeutic framework called the “Collaborative Assessment and Management of Suicidality” (CAMS). Central to CAMS-guided care is the “Suicide Status Form” (SSF), which is a multipurpose assessment, treatment planning, tracking, and outcome-oriented clinical tool (Jobes, 2016). The SSF is among the few suicide risk assessment instruments that applies both quantitative and qualitative methods. This exploratory cross-sectional and descriptive study investigated potential differences and similarities of the experience of suicidality between suicidal patients from six different nations (China, Denmark, Ireland, Norway, Switzerland, and the USA). First session quantitative and qualitative responses to Section A of the SSF completed by N= 362 suicidal patients engaged by CAMS-guided care were examined. Results evidenced significant differences across various quantitative and qualitative variables. Specifically, differences were observed between patients’ ratings of the SSF Core Assessment constructs and their wish to live/wish to die ratings. Qualitative differences were also observed, specifically among the SSF Core Assessment constructs, reasons for living/reasons for dying, suicidal motivation, and One-Thing Response. Several similarities were also observed across both quantitative and qualitative assessments. Specifically, patients did not differ in terms of ranking the SSF Core Assessment constructs in order of importance and no differences were found between patients’ suicidal orientation. Various factors (e.g., sample, setting, severity of risk), along with culturally-driven differences and similarities of the suicidal experience were explored. This was the first-ever study to explore detailed psychological differences of the suicidal experience across this many nations. This dissertation by Blaire C. Schembari fulfills the dissertation requirements for the doctoral degree in Clinical Psychology approved by David A. Jobes, Ph.D., as Director, and by Sandra Barrueco, Ph.D., and Peter M. Gutierrez, Ph.D. as Readers. ________________________________________ David A. Jobes, Ph.D., Director ________________________________________ Sandra Barrueco, Ph.D., Reader ________________________________________ Peter M. Gutierrez, Ph.D., Reader ii Dedication Page To those who are struggling with thoughts of suicide, and to the memory of those we have lost to suicide. iii Table of Contents DOCTORAL DISSERTATION APPROVAL PAGE.……………………………………..….ii TABLE OF CONTENTS……………………….………………………………………………iv LIST OF TABLES………………………………………………………………………...…….xi LIST OF ABBREVIATIONS…………………………………………………………..……...xii ACKNOWLEDGEMENTS…………………...……………………………………………....xiii INTRODUCTION………………………………………………………………………….……1 SSF Assessment Data…..…………………………………………………………………6 Quantitative SSF Research………………………………………………....……………..7 Ratings of SSF core assessment constructs…………………………….….……...7 Rankings of SSF core assessment constructs……………….……………………..8 Self versus other rating……………………………………………………………9 WTL/WTD assessment…………………………………………………………..10 Qualitative SSF Research…………………………………………………..……………11 SSF incomplete sentence prompts….……………………….….…………….….11 SSF reasons for living/reasons for dying………………..……………………….12 SSF one-thing response…………………………………….……………………13 SSF “Micro-Coding”…………………………………………………………….14 SSF “Macro-Coding”…………………………………………………………….14 Suicidal orientation (self vs. relational)………………………………….15 Suicidal motivation (RFL vs. RFD)………………………….…………..17 Limitations of Coding Systems………………………………………………….……….18 Culture and Suicide............................................................................................................19 iv Nations of Comparison......................................................................................................22 China......................................................................................................................22 Denmark.................................................................................................................24 Ireland....................................................................................................................26 Norway...................................................................................................................27 Switzerland............................................................................................................28 The United States of America................................................................................28 Study Rationale and Hypotheses.......................................................................................29 Rationale................................................................................................................29 Hypotheses.............................................................................................................30 METHOD.....................................................................................................................................31 Sample and Participant Selection.......................................................................................31 China......................................................................................................................31 Denmark.................................................................................................................31 Ireland....................................................................................................................32 Norway...................................................................................................................32 Switzerland............................................................................................................32 The USA................................................................................................................32 Procedures..........................................................................................................................32 SSF Translation Methods.......................................................................................33 China..........................................................................................................33 Denmark.....................................................................................................33 Norway.......................................................................................................33 v Switzerland................................................................................................33 Translation methods of qualitative responses from the SSF..................................34 China..........................................................................................................34 Denmark....................................................................................................34 Norway......................................................................................................34 Switzerland................................................................................................34 Measures............................................................................................................................34 Quantitative Methods.........................................................................................................36 Index ratings of SSF core assessment constructs...................................................36 Index rankings of SSF core assessment constructs................................................36 WTL/WTD assessment……..................................................................................36 Qualitative Coding Procedures..........................................................................................37 General coding procedures....................................................................................37 SSF micro-coding..................................................................................................38 SSF core assessment incomplete sentence prompts...................................38 RFL/RFD...................................................................................................39 One-thing response....................................................................................40 SSF macro-coding..................................................................................................41 Suicidal orientation ...................................................................................41 Suicidal motivation....................................................................................42
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