Surviving moment to moment: The experience of living in a state of ambivalence for those with recurrent suicide attempts

Suicide decision-making: Differences in proximal considerations between individuals who aborted and attempted suicide

INTRODUCTION

The transition from suicidal thoughts to behaviors often involves considering the consequences of suicide as part of the decision-making process. This study explored the relationship between this consideration process and the decision to either abort or carry out a suicide attempt.

METHODS

Among inpatients with a suicide-related event in the past 2 weeks (suicide attempt n = 30 or aborted attempt n = 16), we assessed the degree to which they considered six domains of consequences, the impact of these considerations on their inclination to attempt suicide, and the duration of their decision-making.

RESULTS

All the participants who aborted and 87% of those who attempted considered consequences of suicide. Participants who aborted took longer to progress through decision-making stages and considered more suicide-hindering factors, especially interpersonal ones, though these differences were no longer significant after correction. Group status moderated the relationship between the balance of suicide-facilitating and suicide-hindering considerations and decision-making duration. Considering the consequences of suicide more favorably was related to a shorter ideation-to-action period before a suicide attempt and a longer ideation period before aborting an attempt.

CONCLUSION

This study highlights the complexity of suicide decision-making and its role in better understanding the progression from ideation to action.

Suicidal ambivalence: A scoping review

BACKGROUND

Suicidal ambivalence is considered a characteristic condition of suicidal individuals. At the same time, there is a lack of a uniform definition, conception and assessment of suicidal ambivalence. On this background, the current scoping review aims to explore the extent, range, and nature of research activity on suicidal ambivalence and to summarize research findings.

METHODS

A systematic literature search was conducted in four different databases (PubMed, Psychinfo, Web of Science, and Google Scholar) using an array of search terms (e.g., ambivalence, internal suicide debate, reasons for living and reasons for dying, wish to live and wish to die).

RESULTS

In total, 28 articles published between 1977 and 2023 were included in the scoping review. The study situation lacks a clear definition, conceptualization and operationalization of suicidal ambivalence. Nonetheless, suicidal ambivalence is a common experience in persons contemplating suicide and suicidal ambivalence seems to be present before, during and after a suicide attempt. Suicidal ambivalence is associated with diverse markers of negative/positive mental health as well as suicidal ideation and behavior.

CONCLUSION

Results point to the relevance of suicidal ambivalence. At the same time, there are large gaps in knowledge about the development, impact and therapeutic responsiveness of suicidal ambivalence.

Dynamic Associations Among Sleep, Emotion Dysregulation, and Desire to Live in a Perinatal Sample

OBJECTIVE

The present study prospectively examined dynamic associations among sleep, emotion dysregulation, and desire to live during the perinatal transition, as it was theorized that these factors may contribute to the emergence of postpartum suicide risk.

METHOD

Ninety-four women ( Mage = 29.2 years; 23.4% Latina) wore wrist actigraphs and completed twice daily surveys for 7 days during the third trimester of pregnancy, 6 weeks postpartum, and 4 months postpartum. Multilevel, change-as-outcome models were built to examine changes in attractor dynamics among sleep, emotion dysregulation, and desire to live, as well as if sleep-emotion dysregulation dynamics differed based on participants' desires to live.

RESULTS

From pregnancy to 6 weeks postpartum, emotion dysregulation ( B = -0.09, p = .032) and desire to live ( B = -0.16, p < .001) exhibited more stable temporal patterns around higher emotion dysregulation and lower desire to live. Compared to women who reported consistently high desires to live, those who experienced fluctuations in their desires to live exhibited lower, more stable sleep efficiency during pregnancy ( B = -0.90, p < .001). At 4 months postpartum, those with fluctuating desires to live exhibited a coupling dynamic whereby low sleep efficiency predicted increases in emotion dysregulation ( B = -0.16, p = .020).

CONCLUSIONS

This study was the first to examine nonlinear dynamics among risk factors for postpartum suicide, which may be evident as early as pregnancy and 6 weeks postpartum. Sleep health, in particular, warrants further exploration as a key susceptibility factor in the emergence of postpartum suicide risk.

PREREGISTRATION

Open Science Framework ( https://osf.io/qxb75/?view_only=799ffe5c048842dfb89d3ddfebaa420d ).

A qualitative study of young people's lived experiences of suicide and self-harm: intentionality, rationality and authenticity

BACKGROUND

Suicide is a leading cause of death amongst young people and a major public health concern. Although increasing research has identified contributory and protective factors affecting youth suicide, less is known about how young people make sense of suicidal distress themselves.

METHODS

Using semi-structured interview methods and reflexive thematic analysis, this study explores how 24 young people aged 16-24 in Scotland, UK made sense of their lived experiences of suicidal thoughts and feelings, self-harm, and suicide attempts.

RESULTS

Intentionality, rationality, and authenticity formed our central themes. Suicidal thoughts were categorised by participants dependent on their intention to act on them; a distinction often used to downplay the significance of early suicidal thoughts. Escalating suicidal feelings were then described as almost rational responses to adversities; whereas suicide attempts appeared to be described as more impulsive. These narratives seemed to be somewhat shaped by dismissive attitudes participants experienced in response to their suicidal distress, both from professionals and within their close networks. This impacted how participants articulated distress and asked for support.

CONCLUSION

Suicidal thoughts that participants articulated as lacking the intention to act could represent key opportunities for early clinical intervention to prevent suicide. In contrast, stigma, difficulties communicating suicidal distress and dismissive attitudes could serve as barriers to seeking help, and, therefore, additional efforts should be made to ensure young people feel comfortable seeking help.

Ambivalent toward life, ambivalent toward psychotherapy? An investigation of the helping alliance, motivation for treatment, and control expectancies in patients with suicidal ideation in inpatient psychotherapy

BACKGROUND

Research has found that patients with suicidal ideation (SI) are at high risk for unfavorable outcomes. The present work aimed to expand the knowledge about their characteristics and treatment success.

METHODS

Data were drawn from a routine assessment of N = 460 inpatients. We used patients' self-report data as well as therapists' reports covering baseline characteristics, depression and anxiety symptoms (at the start and end of therapy), psychosocial stress factors, helping alliance, treatment motivation, and treatment-related control expectancies. In addition to group comparisons, we conducted tests of associations with treatment outcome.

RESULTS

SI was reported by 232 patients (50.4% of the sample). It co-occurred with higher symptom burden, more psychosocial stress factors, and negation of help. Patients reporting SI were more likely to be dissatisfied with the treatment outcome (although their therapists were not). SI was related to higher levels of anxiety symptoms after treatment. In regression models of depression and anxiety symptoms, interactions of SI with the external control expectancy powerful others were observed, suggesting that in patients with frequent SI, this control expectancy hindered recovery.

DISCUSSION/CONCLUSION

Patients reporting SI are a vulnerable group. Therapists could support them by addressing (potentially conflicting) motivations and control expectancies.

Challenging the Myth of "Attention Seeking" Women with Suicidality: A Grounded Theory Study about Applying Counter-Pressure to Manage System Entrapment

Some women who express suicidal intent and engage in non-lethal self-harm perceive that nurses and other health care workers label them as attention-seeking and manipulative. An understanding of women's help-seeking behaviors that challenges suicide myths is presented. The purpose of this study was to examine help-seeking for suicidality in women with histories of intimate partner violence using a multiple qualitative research design of grounded theory and photovoice. Women from New Brunswick, Canada, over the age of 19 who left an abusive partner (n = 32) were interviewed and seven local women from this sample participated in five photovoice group sessions where they collectively examined self-generated photos of their experiences. Transcripts of the interviews and group sessions were analyzed using the constant comparative approach, yielding a theoretical rendering of women's help seeking. Results include a process of Applying Counter-Pressure as a way of pushing back against System Entrapment, or the sense of being invalidated and dehumanized by health care providers with the goal to Feel Human. Findings provide an understanding of women's behavior when seeking help for suicidality and may reduce nurses' assumptions and judgments when providing care. Trauma and violence informed care provides a framework from which to guide interventions that acknowledge the role of past and ongoing trauma in women's lives, supporting nurses' capacity to be validating and helping women to continue living.

The path not taken: Distinguishing individuals who die by suicide from those who die by natural causes despite a shared history of suicide attempt

OBJECTIVES

This study aimed to identify variables that distinguish suicide risk among individuals with previous suicide attempts.

METHOD

Using psychological autopsy procedures, we evaluated 86 decedents who had at least one lifetime suicide attempt before eventual death by suicide (n = 65) or natural causes (n = 21).

RESULTS

The Suicide Death group was more likely to be male, to have alcohol in the toxicology report at time of death, and to have a depression diagnosis, while the Natural Cause Death group was more likely to have personality disorder traits, a polysubstance use disorder, higher reported health stress, and an antidepressant in the toxicology report at time of death. Hopelessness and ambivalence were found to distinguish between groups during the 6 months before death.

CONCLUSIONS

These findings suggest important differences between individuals with a shared history of a suicide attempt who die by suicide versus natural causes.

Valued attributes of professional support for people who repeatedly self-harm: A systematic review and meta-synthesis of first-hand accounts

Therapeutic interventions are an important adjunct to self-help strategies for people who self-harm. There is little guidance for those offering therapy on the effective components of interventions for people who self-harm. This was a systematic review aiming to identify the factors that contribute to positive experiences of therapy as described by people who have reduced or stopped self-harm. The review followed PRISMA guidelines to locate and synthesize peer-reviewed qualitative studies describing experiences of therapy among people who had reduced or stopped self-harm. Study selection, data extraction, and quality assessment were peer reviewed and conducted for at least two researchers independently. Relevant first-hand quotations were extracted from eligible studies and synthesized using a thematic analysis in collaboration with experts with personal and professional experience of self-harm. Twenty-three studies met eligibility criteria. Themes identified in the reported accounts were arranged under two meta-themes. 'Positive aspects of seeing a professional' identified aspects of professional care that were common to all encounters: the value of sharing, space to talk and reflect, and the boundaries inherent in contact with a professional. 'Positive attributes of individual professionals' depended upon individual characteristics: the ability to build reciprocal trust by being non-judgemental, showing genuine empathic concern, and being confident to talk about and respond directly to self-harm. Our review indicates that therapeutic alliance is perceived as key to effective professional help for self-harm, irrespective of underlying principles of therapy. All forms of therapy should be timely and reliable and centred around the needs of the individual and their experience of self-harm.

The association between uncertainty and mental health: a scoping review of the quantitative literature

BACKGROUND

The current moment is characterised by deep-rooted uncertainties, such as climate change and COVID-19. Uncertainty has been reported to be associated with negative mental health outcomes, such as stress and anxiety. However, no comprehensive review on the association between uncertainty and mental health exists.

AIM

The aim of the current scoping review was to systematically explore and describe the literature on the link between uncertainty and mental health.

METHODS

A scoping review was undertaken following guidelines by Arksey and O'Malley (2005).

RESULTS

One hundred and one papers addressing the association between uncertainty and mental health were identified. Most were cross-sectional studies (67%) conducted in the fields of medicine or nursing (59%), in high-income countries, among adult populations (74%), and in medical settings. Substantial heterogeneity was identified in the measurements of uncertainty and mental health. Most studies (79%) reported a positive association between uncertainty and mental health problems.

CONCLUSIONS

Research is needed in more diverse contexts and populations. More robust designs are required to provide insight into the directionality and strength of the association between uncertainty and mental health. Few studies reported how individuals coped with uncertainty. Future studies should address the identified gaps and investigate interventions to address uncertainty and its determinants.

An investigation of whether emotion regulation mediates the relationship between attachment insecurity and suicidal ideation and behaviour

OBJECTIVE

The aim of this research was to examine relationships between attachment insecurity and suicidal ideation and behaviour. Secondary aims were to explore the mediating role of emotion dysregulation and the moderating role of betrayal trauma in explaining hypothesised relationships.

METHOD

Sixty-five participants with experience of suicidal ideation completed questionnaire measures assessing attachment security, suicide ideation, emotion regulation, betrayal trauma, depressive symptoms and hopelessness.

RESULTS

A direct relationship was found between avoidant attachment and suicide ideation after controlling for age and gender. Multiple suicide attempters had higher anxious attachment. Anxious and avoidant attachment, suicide ideation and betrayal trauma were associated with emotion dysregulation. The relationship between attachment insecurity and suicide ideation was not mediated by emotion dysregulation. In the mediation model, only anxious attachment remained a significant predictor of emotion regulation and there was no significant effect of emotion regulation nor betrayal trauma, on suicide ideation.

CONCLUSION

Suicidal individuals may benefit from therapeutic intervention that explores attachment-related difficulties and therapies such as dialectical behavioural therapy, which support skills in emotional regulation. Future longitudinal research should identify other important mediators of the association between attachment and suicidality to develop more targeted psychological interventions for suicidality.

Measuring the impact of suicide attempt posttraumatic stress

OBJECTIVE

To examine the associations between posttraumatic stress symptoms (PTS) following a medically serious suicide attempt with suicidal ideation, related interpersonal constructs, and outpatient mental health service utilization.

METHODS

The study utilized an existing data set from a clinical trial consisting of 66 patients recruited at a level 1 trauma center following medical admission for a suicide attempt. Measures of suicide attempt-related PTS (SA-PTS), suicidal ideation, perceived burdensomeness, thwarted belongingness, and outpatient medical and mental health utilization were completed at 1 and 3 months. A series of mixed-effects regression models were used to analyze the data.

RESULTS

Greater SA-PTS at 1 month was associated with significantly greater suicidal ideation, thwarted belongingness, and perceived burdensomeness across 1 and 3 months.

CONCLUSIONS

Addressing PTS following a medically serious suicide attempt may aid in addressing suicide-specific constructs and improve the recovery trajectory following hospitalization.

Strategies to Stay Alive: Adaptive Toolboxes for Living Well with Suicidal Behavior

Suicidal behavior constitutes a major global problem. Qualitative research utilizing the first-hand experiences of those who have survived attempts to take their own lives can offer much in the way of understanding how to live well despite ongoing suicidal behavior. Given that suicidal intentions and behaviors occur within the person’s subjective construal, the solutions to living—and preferably living well—despite such inclinations must also be subjective and adaptive. The aim of this study was therefore to understand how individuals live with different aspects of their suicidal behavior and their use of effective strategies to protect themselves from future attempts. Thematic analysis of semi-structured, qualitative interviews with 17 participants with lived experience of suicidal behavior from the USA yielded two main themes: (i) the ‘dynamic relationship with suicidal behavior: living with, and through’, and (ii) ‘the toolbox’. Each of these themes had four subthemes. Participants in this study offered important insights into what helped them not just survive ongoing suicidal behavior, but how they created unique toolboxes to continue living, and to live well. These toolboxes contained personalized solutions to dealing with recurring threats to their subjective wellbeing and included diverse solutions from spirituality, pets, peer-support, participating in the arts, through to traditional therapeutic supports. Some participants also discussed the importance of broader social policy and societal changes that help them live. The findings highlight crucial implications for suicide prevention efforts, especially in terms of encouraging collaborations with the lived experience community and furthering a strengths-based approach to mitigating suicidal behaviors. We encourage the clinical community to work in partnership with service-users to enable them to generate effective solutions to living—and living well—through suicidal behavior.

Opioid overdose experiences in a sample of US adolescents and young adults: a thematic analysis

BACKGROUND AND AIMS

Opioid overdose deaths among adolescents and young adults have risen sharply in the United States over recent decades. This study aimed to explore the nature of adolescent and young adult perspectives on overdose experiences.

DESIGN

This study involved thematic analysis of interviews undertaken as part of a mixed-methods, randomized trial of extended release naltrexone (XR-NTX) versus treatment-as-usual (TAU) for adolescents and young adults (aged 15-21 years) with opioid use disorder (OUD).

SETTING

Participants were recruited during a residential treatment episode at Mountain Manor Treatment Center, in Baltimore, MD, USA.

PARTICIPANTS/CASES

As part of the qualitative component of this study, 35 adolescents/young adults completed up to three interviews: at baseline, 3 and 6 months after release from residential opioid use disorder treatment.

MEASUREMENTS

Semi-structured interviews solicited participant experiences with opioid use disorder treatment; their satisfaction with the medications used to treat opioid use disorder; counseling received; current substance use; issues related to treatment retention; their treatment goals; and their future outlook.

FINDINGS

Four broad themes emerged: (1) adolescents/young adults had difficulty identifying overdoses due to interpreting subjective symptoms and a lack of memory of the event, (2) this sample had difficulty perceiving risk that is misaligned with traditional understandings of overdose intentionality, (3) adolescents/young adults did not interpret personal overdose events as a catalyst for behavior change and (4) this sample experienced a greater impact to behavior change through witnessing an overdose of someone in their social network.

CONCLUSIONS

The sample of US adolescents and young adults in treatment for opioid use disorder expressed difficulty identifying whether or not they had experienced an overdose, expressed fluctuating intentionality for those events and did not have clear intentions to change their behavior. Witnessing an overdose appeared to be as salient an experience as going through an overdose oneself.

The Psychological Pathway to Suicide Attempts: A Strategy of Control Without Awareness

Objectives

This paper aims to identify potential areas for refinement in existing theoretical models of suicide, and introduce a new integrative theoretical framework for understanding suicide, that could inform such refinements.

Methods

Literature on existing theoretical models of suicide and how they contribute to understanding psychological processes involved in suicide was evaluated in a narrative review. This involved identifying psychological processes associated with suicide. Current understanding of these processes is discussed, and suggestions for integration of the existing literature are offered.

Results

Existing approaches to understanding suicide have advanced the current knowledge of suicide in various ways. They have guided valuable research in the following areas: motivations for suicide and the psychological distress which influences suicide attempts; ambivalence about suicide; suicidal individuals’ focus of attention; and ways in which individuals who contemplate suicide differ from individuals who attempt suicide. We outline a new theoretical framework as a means to integrating all of these concepts into the three principles of control, conflict, and awareness. Within this framework, suicide is regarded as occurring due to a long standing conflict between an individual’s personal goals, culminating in an episode of acute loss of control. The new framework posits that the individual then strives to regain control through the means of suicide because of a narrowed awareness of consequences of their actions on other valued goals. This psychological mechanism of limited awareness is posited to be the common pathway by which individuals make a suicide attempt, regardless of which risk factors are present.

Conclusion

This article introduces a theoretical framework that generates several hypotheses for future research, and focuses on psychological processes occurring during immediate crisis. One of the key hypotheses resulting from our predictions on how individuals progress from contemplating to attempting suicide will be tested in an ongoing program of research: Individuals who attempt suicide have a significantly reduced awareness of consequences of suicide, which would negatively impact on their important life goals, values, principles, or ideals, compared to individuals who contemplate suicide. Therapy guided by the new framework may be more flexible, immediate, and client-focused than other therapies for suicidal individuals.

Psychiatric consultations as a modifiable factor for repeated suicide attempt-related hospitalizations: A nationwide, population-based study

BACKGROUND

The risk of mortality and morbidity increased in repeated suicide attempts. This study aimed to investigate how psychiatric consultations, a modifiable factor, affects the risk of repeated suicide attempts in patients.

METHODS

The National Health Insurance Research Database was used in this study. All inpatients aged ≧10 with suicide attempts were recruited in Taiwan from 2000 through 2015. Both the cross-sectional and cohort studies were used to evaluate the risk of repeated suicide attempts associated with psychiatric consultations.

RESULTS

In the cross-sectional approach, a total of 88,161 suicide attempts and 7,997 with repeated suicide attempts were found. Multivariable logistic regression found that the patients with psychiatric consultations were associated with the decreased risk of repeated suicide attempt-related hospitalization (SARD), as per the adjusted odds ratio of 0.527 (95% confidence interval [CI]=0.416-0.859, p <0.001). In the retrospective cohort approach, the Fine and Gray's survival analysis revealed that the patients with psychiatric consultations were associated with a lower risk of repeated SARD (adjusted subdistribution hazard ratio [SHR] =0.533( 95% CI, 0.332-0.850, p <0.001).

CONCLUSIONS

Overall, psychiatric consultations for the patients could be a modifiable factor, which were associated with the decreased risk of repeated suicide attempts. The age of clinicians and their experience could be the primary variable above and beyond the mental illness or the performed suicide attempt method.

Alexithymia in People With Recurrent Suicide Attempts

Background: Alexithymia, an inability to identify or describe emotions, is associated with suicidality yet the correlation with single or repeated suicide attempts is less clear. Aims: We aimed to assess the modifiability of alexithymia following a group psychosocial intervention focused on improving emotional literacy in those with a history of recurrent suicide attempts (RSA). Method: A total of 169 participants with self-reported RSA completed pre- and postgroup assessments of a 20-week group therapy intervention. Questionnaires assessed alexithymia, depression, impulsivity, and hopelessness; the Toronto Alexithymia Scale (TAS-20) was the primary outcome. Data were analyzed using multiple imputation. Results: Participants had on average 7.8 lifetime suicide attempts, 73% were female, and 16.6% had a >13-point reduction in TAS-20 scores after 20 weeks. Directed acyclic graph (DAG) analysis demonstrated significant relationships between alexithymia, depression, hopelessness, problem-solving, and satisfaction with life. Age of onset of suicidality was the only factor predictive of postintervention TAS-20 score in univariate linear regression. Limitations: The study limitations were its sample size, insufficient resources, and missing data. Conclusion: A change in TAS scores indicated that alexithymia can be a modifiable treatment target. Being able to identify and describe feelings may lead to improvement in depression, hopelessness, problem-solving, and satisfaction with life in this population.

Prefrontal activation in suicide attempters during decision making with emotional feedback

Emotional feedback, such as faces showing emotions, can influence decision making. Decision making and emotional face processing, mainly mediated by the prefrontal and cingulate cortices, are impaired in suicide attempters. Here, we used functional MRI (fMRI) to study prefrontal activation in suicide attempters during a modified version of the Iowa Gambling Task (IGT) that included emotional face feedback. We randomly distributed the 116 euthymic women (n = 45 suicide attempters, n = 41 affective controls with history of depression without suicide attempt, and n = 30 healthy controls) included in the study in three emotional IGT groups: concordant (safe and risky choices followed by happy and angry faces, respectively), discordant (safe and risky choices followed by angry and happy faces, respectively), and neutral condition (safe and risky choices followed by neutral faces). Considering the two IGT phases (ambiguous and risky), we then analyzed five regions of interest during the risky vs. safe choices: orbitofrontal (OFC), anterior cingulate (ACC), ventrolateral (VLPFC), medial (MPFC) and dorsal prefrontal (DPFC) cortices. We found: (1) impaired decision making and increased DPFC and OFC activation in suicide attempters vs. controls in the discordant condition during the risky phase; (2) reduced VLPFC activation in suicide attempters in the concordant condition during the ambiguous phase; and (3) decreased OFC, ACC and DPFC activation in both control groups in the concordant condition during the ambiguous phase. Suicide attempters showed prefrontal alterations during reward-learning decision making with emotional feedback. Suicide attempters may guide their decisions to avoid social negative feedback despite the expected outcome.

Suicidal motivations reported by opioid overdose survivors: A cross-sectional study of adults with opioid use disorder

BACKGROUND

Prior studies in heroin use disorder reported low rates (10%) of suicidal intention with non-fatal opioid overdose but did not assess dimensional ratings of suicidal ideation. This study aims to quantify the frequency and intensity of ratings of desire to die and perceived overdose risk proximal to the most recent opioid overdose event among individuals admitted for opioid use disorder detoxification/stabilization.

METHODS

Cross-sectional study (June 2017-July 2018) assessing patterns of opioid use and variables related to overdose history was conducted in a not-for-profit psychiatric hospital. Adults (>18 years) with opioid use disorder were eligible and 120 of 122 participants completed all measures. Forty-one percent were women and 85% self-identified as white. Participants' perceptions of the likelihood of overdose and their suicidal motivations (defined as desire to die) prior to most recent opioid overdose was self-rated on a scale of 0 (no desire to die/no risk of death) to 10 (I definitely wanted to die/I definitely thought I would die).

RESULTS

Most (92%) surviving opioid overdose used heroin/fentanyl; over half reported some desire to die prior to their most recent overdose, with 36% reporting strong (>7/10) desire to die and 21% reporting 10/10 "I definitely wanted to die." Perceptions of overdose risk were also variable, with 30% reporting no (0/10) likelihood of overdose and 13% reporting a high (10/10) likelihood.

CONCLUSIONS

Suicidal motivation prior to opioid overdose is common and falls along a continuum of severity. Longitudinal studies are needed to determine if suicide prevention interventions may reduce opioid overdose in those at risk.

Lived Experiences of Suicide Risk and Resilience among Alaska Native and American Indian People

This study explored the lived experiences of suicidality and help-seeking for suicide prevention among Alaska Native and American Indian (AN/AI) people in a tribal health system. An interpretive phenomenological approach was used to analyze semi-structured, in-depth interviews with 15 individuals (ages 15-56) with self-reported histories of suicide ideation and/or attempt. Several factors were found to be central to acquiring resilience to suicide risk among AN/AI people across a wide age range: meaningful and consistent social connection, awareness about how one's suicide would negatively effect loved ones, and knowledge and utilization of available health services. Findings highlight the mutable nature of suicide risk and resilience, as well as the importance of interpersonal factors in suicidality.