1. Introduction
Suicide is a significant issue in public health policies worldwide [1]. It is a phenomenon that is influenced by biological factors, psychological variables, and contextual factors [2,3]. Each death by suicide has a direct and indirect impact on family, friends, and the community [4]. Research has shown that adolescence is a vulnerable period for suicide ideation and behaviour [5] due to the development-related challenges it presents [6]. In fact, previous studies have found that suicide-related thoughts tend to begin at this stage [7] and recent data have shown that suicide is the second most common cause of non-natural death among adolescents aged 15 to 19 in Spain [8] and worldwide [1].
Suicidal behaviour is a complex, multidimensional, multifactorial, fundamentally psychological phenomenon, characterized by the presence of suffering and intolerable psychological pain in which a person decides to end their life under certain circumstances (feeling no longer able to cope with suffering, that their suffering is interminable, or they are without a future or hopeless). It includes a variety of manifestations, including ideation and planning, suicidal communication, suicidal attempts, and completed suicide [9,10]. Recent research has conceptualized suicidal behaviour through the ideation-to-action framework, showing that factors related to suicide ideation are different from those related to suicide attempts [11,12]. Following this approach, suicidal behaviour should not be understood as equivalent to death by suicide. The different phenotypic manifestations of the behaviour are on a continuum of severity, in which the risk will be higher for a person who is closer to the suicide end of it [13]. Although it may seem to follow a linear trajectory, there are non-linear, discontinuous changes over time and in fact suicidal behaviours can appear suddenly without prior suicidal planning [14]. Human behaviour does not conform well to the linear and unilateral [15]. There is still no consensus on its conceptual definition and taxonomy, which has an impact on, among other things, the understanding, assessment, and prevention of as well as interventions for suicidal behaviour [16,17,18]. Recent data show that about 30% of Spanish adolescents present suicidal ideation, and 4% have suicide attempted suicide [19,20]. Multiple studies have examined this issue [5,21]; however, it remains a silent problem in society [3].
Understanding suicidal behaviour in adolescence requires us to consider the quality of parent–child relationships [22]. Family conflict is one of the most widely studied topics [23] since it is associated with a higher likelihood of suicidal ideation [24] and has been found to be one of the most consistent, robust factors related to suicidality and other behavioural problems during adolescence [25,26]. Similarly, the family component is an essential aspect in managing this problem in the adolescent population [10,15,27], being a key element in evidence-based interventions, such as dialectical behaviour therapy [28], and also having a crucial role in implementing suicide-prevention strategies outside of treatment [29].
For many adolescents, conflict in the family may overwhelm their coping mechanisms, making those with poorer coping skills particularly vulnerable [21]. Moreover, a negative interpretation of these conflicts, in which there is a pessimistic view of the course of family events, may influence an adolescent’s well-being and distress reactions during disputes [30,31], which is associated with suicidal behaviour [32]. One important variable associated with healthy social relationships is assertiveness, defined as the ability to express one’s opinions and needs, while respecting the opinions and needs of others [33]. Assertiveness is associated with cognitive interpretations of the social world, including one’s views of oneself and others and the interactions between the two [34]. These cognitive interpretations are interpersonal schemas, defined as beliefs associated with interpersonal events and relationships. In this vein, the rigidity of schemas and limited responses are related to interpersonal problems [35] and interpersonal misperceptions [36], constituting a risk factor for psychological distress [37]. In contrast, the assertive interpersonal schema is one’s ability to understand interpersonal conflicts as normal and manageable [38]. The assertive interpersonal schema has been studied in relation to other adolescent problems, such as violence in teen dating [39]; however, no studies have specifically examined this variable in relation to suicidal behaviour. The influence of the cognitive aspect of assertiveness could be important because the interpretation of social interactions has a relevant role in adolescents’ psychosocial adjustment [40,41].
Previous studies have examined possible mediating variables in the relationship between family conflict and suicidal behaviour. For instance, a study [42] found that family conflict was associated with a higher suicide risk and that depressive symptomatology mediated this relationship in a residential sample of adolescents and young adults. In addition, a recent study [22] suggested that variables, such as impulsivity, behavioural patterns, and social information processing, mediate the relationship between family conflict and suicidal ideation and attempts. However, despite the existing research highlighting the importance of studying the mediating variables between family conflict and suicide-related variables, to our knowledge, no studies have explored the role of the assertive interpersonal schema in this relationship. Considering that adolescence is a vulnerable stage for behavioural problems [43], such as suicidal behaviour [44], and that adolescence is a period in which the assertive interpersonal schema and interpersonal skills are developed [38], examining this question could provide important information with implications for suicide prevention and interventions.
The main aim of the present study was to examine the direct and indirect effects of family conflict on suicidal ideation, suicide attempts, and the total suicidal behaviour score (Paykel Suicide Scale) through the assertive interpersonal schema in a sample of adolescents between 14 and 18 years old.
2. Materials and Methods
This is a cross-sectional study, and the STROBE checklist can be found in the Supplementary Materials.
2.1. Participants
The target population was 232 Spanish adolescents from a secondary school in the east of Spain selected by convenience sampling. Inclusion criteria for participating in the study were as follows: (1) the participant could provide a parent’s or legal guardian’s written informed consent; and (2) the participant was willing to participate. Most of the target population agreed to participate (98.71%) and the final study sample comprised 229 participants (52.8% boys; Mage = 15.76 years; SD = 1.24; range = 14–17). Data were collected during 2019–2020 academic year.
2.2. Instruments
An ad hoc questionnaire in Spanish was administered to collect sociodemographic information (age, sex, ethnicity, school year). The following instruments were used to collect specific data:
2.2.1. Paykel Suicide Scale (PSS)
Suicidal behaviour was measured using the PSS [20,45]. This is a suitable instrument for screening for this issue in the adolescent population in educational contexts [20]. It consists of five yes-or-no questions about the previous two weeks. Items 1 and 2 refer to thoughts about death, items 3 and 4 are about suicidal thoughts, and item 5 refers to suicide attempts. For the present study, we considered suicidal ideation to be the sum total of items 1 to 4, suicide attempts to be item 5, and suicidal behaviour to be the total score. The Spanish adaptation of the PSS has demonstrated adequate psychometric properties [20]. In this sample, the Cronbach’s alpha was 0.66.
2.2.2. Strategic Family Evaluation (EFE)
The EFE [46] is a self-reported instrument assessing five constructs about family dynamics (communication, social support, conflict, rules, and consequences). Items are rated on a five-point Likert scale (1 = never; 5 = always). The original instrument assesses these variables for each family member; however, in the present study, we asked about family conflict in general. The Spanish version of the EFE was used in the present study [46]. In this sample, the Cronbach’s alpha for family conflict was 0.86.
2.2.3. Assertive Interpersonal Schema Questionnaire (AISQ)
The AISQ [38] is a self-reported instrument assessing five constructs about cognition in assertiveness (outer emotional support, functional personal ability, interpersonal management, and affective personal ability). Items are rated on a five-point Likert scale (1 = not at all like me; 5 = completely like me). The answers of each construct are added together for the total score [38]. The AISQ has demonstrated adequate psychometric properties [38]. In this sample, the Cronbach’s alpha was 0.90.
2.3. Procedure
The study was approved by the Ethical Research Committee of Aragon (Spain) and the Research Ethics Committee of Valencian International University (Spain). The study was conducted in accordance with the Declaration of Helsinki and complied with the ethical standards established in current Spanish data protection and digital rights legislation. Parents or legal guardians signed the informed consent form after being told about the voluntary nature of the students’ participation in the study. The questionnaires were completed in the students’ regular classroom (taking approximately 30–40 min) under the researcher’s supervision.
2.4. Analytic Strategy
Preliminary analyses included descriptive statistics of the study variables and Pearson correlations. Simple mediation analyses were performed using Model 4 of the PROCESS macro, which is an interface applied to SPSS to conduct ordinary least squares (OLS) and logistic regression path analysis modelling [47]. Three models were tested; family conflict was the independent variable (X), the assertive interpersonal schema was the mediator (M), and suicidal ideation (composite score of items 1 to 4 on the PSS), suicide attempts (yes vs. no on PSS item 5), and suicidal behaviour (PSS total score) were the dependent variables (Y) (see Figure 1). Age and sex were not included as covariates in the mediation models due to the lack of significant relationships to the study variables in bivariate analysis.
To generate confidence intervals for assessing indirect effects, we used bias-corrected bootstrapping (with 20,000 resamples) [48]. The formula was used to estimate the magnitude of the mediating effect. Indirect effects are considered significant if the upper and lower bounds of the bias-corrected 95% confidence intervals (95% CI) do not contain zero [49]. The direct effects represent the relationship between X and Y not attributable to M.
Due to the cross-sectional nature of the data, which prevented the establishment of causal relationships, reverse models were also conducted for each outcome variable to evaluate the hypothesized models’ specificity [48].
3. Results
Descriptive statistics, including the means, standard deviations, skewness, kurtosis, and Pearson correlations of the study variables, are presented in Table 1 and Table 2, respectively. When examining the normality of the data distribution by skewness and kurtosis, none of the variables were outside the acceptable ranges (skewness < 3 and kurtosis < 10) [50].
Of the total sample, 31.4% (n = 72) of the participants reported suicidal ideation and 4.80% (n = 11) reported suicide attempts. Approximately a third of the sample reported some kind of suicidal behaviour (31.4%; n = 72).
3.1. Mediation Analysis
The three mediation models showed a statistically significant direct effect of family conflict (path c′) on suicidal ideation, suicide attempts, and suicidal behaviours. When examining the indirect effect of family conflict on suicidal ideation via the AISQ total scores (Table 3), the indirect effect was significant (a*b = 0.08, 95% CI (0.03, 0.14)). For the effect of family conflict on suicide attempts, the indirect effect was significant (a*b = 0.05, 95% CI (0.01, 0.11)). Finally, the indirect effect through the PSS total score was also significant (a*b = 0.08, 95% CI (0.02, 0.14)). Almost three-quarters (72.7%) of the association between family conflict and suicidal ideation was mediated by the assertive interpersonal schema, while 23.8% of the association between family conflict and suicide attempts was mediated by it. For the total score on the PSS, 66.6% of the relationship between the study variables was mediated by the assertive interpersonal schema.
3.2. Reverse Mediation Analysis
For suicidal ideation (a*b = 0.03, 95% CI (−0.07, 0.01)), suicide attempts (a*b = −0.01, 95% CI (−0.02, 0.01)), and the total suicide behaviour score (a*b = −0.03, 95% CI (−0.08, 0.01)), the results of the reverse models were not significant.
4. Discussion
The aim of the present study was to examine the direct and indirect effects of family conflict on suicidal behaviour through the assertive interpersonal schema in a sample of adolescents. The results showed that family conflict was significantly related to suicidal ideation, suicide attempts, and the total suicidal behaviour score. This supports previous research showing that family conflict is a robust risk factor for suicidality [25,27]. Our results also showed an indirect effect of family conflict on suicidal ideation, attempts, and total suicidal behaviour score through the assertive interpersonal schema.
From the suicide-related data, we found that 29.7% of the participants reported suicidal ideation, and 4.8% indicated having attempted suicide in the previous two weeks. These findings are in line with those of previous studies with other samples of adolescents. For instance, a review examining data from 11 different countries reported suicidal ideation ranging between 10% and 35%, and attempts between 5% and 15% [51]. Our results are also consistent with previous studies in Spain that obtained similar data about suicidal ideation and attempts [18,20].
The mediation analysis data indicated a direct effect of family conflict on suicidal ideation. Other authors have found similar results, highlighting family conflict as one of the most stressful reported factors related to suicidal ideation [52,53]. The literature has established that specific stressors, such as family conflict, may trigger suicidal ideation, especially when a person presents vulnerabilities, such as personality traits or contextual variables [5,11]. Further research is warranted to examine other variables that could also be implied in this relationship. Our data also showed an indirect effect of family conflict on suicidal ideation via the assertive interpersonal scheme, explaining 72% of the relationship. One possible explanation of this finding is that the interpersonal assertiveness scheme is associated with the use of adaptative skills to better manage the distress produced by family conflict [54,55] and therefore influences suicidal ideation.
There were similar results for suicide attempts, since family conflict also had a direct effect on this variable. These results are consistent with those of the previous literature. For instance, a study [56] found that 5.41% of adolescents reported family conflict as a motive for attempting suicide. Along similar lines, a recent meta-analysis [21] showed that adolescents with a history of suicide attempts presented more parental-related stress than those without suicidal behaviour. Moreover, family conflict was also indirectly related to suicide attempts through the assertive interpersonal scheme, explaining 23% of the relationship. Therefore, family conflict is a relevant variable associated with suicide attempts [23]. However, future research should also consider other variables to understand the shift from ideation to action, such as exposure to others’ suicidal behaviour or having a suicide plan [11].
The results were similar in terms of suicidal behaviour, which includes ideation and attempts: family conflict had a significant direct and indirect effect through the assertive interpersonal scheme, explaining 66% of this relationship. This finding supports the approach of the ideation-to-action framework, which proposes that the study of suicidal behaviour should consider suicide ideation and suicide attempts as different phenomena [57]. This has clinical implications in terms of prevention and treatment programs, highlighting the need to distinguish between ideation and action, and the need to tailor intervention components according to this information [58].
Several studies have highlighted the importance of considering the influence of family on suicidal behaviour in adolescents [22] as well as its influence on other problematic behaviours, such as alcohol [59], tobacco (traditional and electronic cigarettes) [60], and cannabis use [61]. Suicidal behaviour has also been associated with emerging problems, such as problematic internet use, in which the role of the family through parental control is particularly important [62]. Our findings have clinical implications for preventing and treating suicidal behaviour. First, the results highlight the importance of family relationships to adolescent psychological well-being, in line with previous research showing that they can act as a protective factor or as a risk factor [63]. Furthermore, since family is considered one of the main educational agents promoting adolescent personal development [64], prevention and treatment programs should consider not only the involvement of family members but also training in conflict management skills. Second, our data showed that the assertive interpersonal schema plays a role in how family conflict has an impact on suicidal behaviour. Therefore, in line with Vagos and Pereira [38], who noted the importance of this scheme in improving social skills, it may be beneficial to include components addressing this scheme in the prevention of and interventions for suicidal behaviour in adolescents. Indeed, a recent review of programs for those at risk of suicide found that the most effective interventions included family and skills training as emotion regulation skills [65]. Future research is needed to test whether including such components improves treatment outcomes [66].
Our study does have some limitations. Firstly, it was a cross-sectional study, and causal and temporal associations cannot be established. However, to increase our confidence in the results of the study, we conducted reverse models which showed a non-significant indirect effect of the assertive interpersonal scheme on suicidal ideation, attempts, and the total suicidal behaviour score through family conflict, adding credence to our proposed interpretation. Secondly, the sample available to us was not large. Talking about suicide remains complicated because it is a topic that is surrounded by stigma [9]. Third, suicidal behaviour was assessed through a self-reported instrument that, although frequently used for suicidal behaviour screening in adolescents [19], did not allow for a deeper examination of participants’ despair, psychological pain, or other suicide-related aspects, such as passive ideation, active ideation, or suicide planning. Moreover, the self-reported nature of the instrument raises potential concerns about social desirability and response bias, which might be especially important during adolescence.
The current study also has its strengths. The phenomenon of suicide was analysed considering the emerging theories of intention-to-action, examining its components separately [11]. This is the first study considering the assertive interpersonal schema, yielding relevant results for suicidal behaviour prevention and intervention efforts.
5. Conclusions
The current study contributes to the literature highlighting the importance of family conflict in suicidal behaviour and introducing the assertive interpersonal schema as a factor to be considered. More specifically, our findings indicate that family conflict is positively related to suicidal ideation and suicide attempts, with the assertive interpersonal schema having an important role as a mediator variable. To our knowledge, our study is the first to consider this variable as a mediator, thus highlighting the relevance of this personal ability.
Conceptualization, S.A.-H., V.J.V.-B., D.E. and C.M.-V.; methodology, S.A.-H., V.J.V.-B., D.E. and C.M.-V.; software, C.M.-V.; validation, S.A.-H., V.J.V.-B. and C.M.-V.; formal analysis, C.M.-V.; investigation, D.E. and V.J.V.-B.; resources, V.J.V.-B. and D.E.; data curation, D.E. and C.M.-V.; writing—original draft preparation, D.E., C.M.-V. and V.J.V.-B.; writing—review and editing, S.A.-H. and J.M.E.; visualization, S.A.-H., V.J.V.-B., D.E. and C.M.-V.; supervision, S.A.-H. and V.J.V.-B.; project administration, S.A.-H. and V.J.V.-B. All authors have read and agreed to the published version of the manuscript.
The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethical Research Committee of Aragon (Spain) and the Research Ethics Committee of Valencian International University (Spain).
Informed consent was obtained from all subjects involved in the study.
The data presented in this study are available upon request from the corresponding author.
The authors wish to thank the secondary school centres and participants involved in this study.
The authors declare no conflict of interest.
Footnotes
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Descriptive statistics of study variables (n = 229).
| % (n)/M (SD) | Skewness | Kurtosis | |
|---|---|---|---|
| Family conflict | 9.61 (3.25) | 1.252 | 1.149 |
| AISQ—Total | 86.50 (11.27) | −0.984 | 0.988 |
| PSS—SI (range 0–4) | 0.49 (0.89) | 2.019 | 3.819 |
| PSS—SA (yes) | 4.80 (11) | -- | -- |
| PSS—SB (range 0–5) | 0.54 (0.99) | 2.299 | 5.744 |
Note. AISQ = Assertive Interpersonal Schema Questionnaire; PSS—SI = Suicidal Ideation; PSS—SA = Suicide Attempts; PSS—SB = Total Suicide Behaviour score.
Bivariate correlations among study variables (n = 229).
| 1 | 2 | 3 | 4 | 5 | 6 | |
|---|---|---|---|---|---|---|
| 1. Age | - | |||||
| 2. Sex | 0.08 | - | ||||
| 3. Family conflict | 0.09 | −0.02 | - | |||
| 4. AISQ—Total | −0.01 | −0.07 | −0.22 *** | - | ||
| 5. PSS—SI | −0.02 | −0.12 | 0.21 ** | −0.38 *** | - | |
| 6. PSS—SA | 0.03 | −0.07 | 0.19 ** | −0.23 *** | 0.36 *** | - |
| 7. PSS—SB | −0.01 | −0.12 | 0.23 *** | −0.39 *** | 0.54 *** | 0.98 *** |
Note. AISQ = Assertive Interpersonal Schema Questionnaire; PSS—SI = Suicidal Ideation; PSS—SA = Suicide Attempts; PSS—SB = Total Suicide Behaviour score. ** p < 0.01; *** p < 0.001
Simple mediational analysis results (n = 229).
| Suicidal Ideation | |||||
|---|---|---|---|---|---|
| Direct | b a | p | LLCI b | ULCI c |
|
| Family conflict → AISQ (a1) | −0.22 | <0.001 | −1.21 | −0.328 | |
| AISQ → PSS-SI (b1) | −0.35 | <0.001 | −0.04 | −0.02 | |
| Family conflict → PSS—SI (c′) | 0.03 | 0.042 | 0.01 | 0.06 | |
| Indirect d | b | BooLLCI e | BooULCI f | ||
| Family conflict → AISQ → PSS—SI | 0.08 | 0.03 | 0.14 | 0.72 | |
| Suicide Attempts | |||||
| Direct | b a | p | LLCI b | ULCI c |
|
| Family conflict → AISQ (a1) | −0.22 | <0.001 | −1.21 | −0.328 | |
| AISQ → PSS-SA (b1) | −0.06 | <0.01 | −0.11 | −0.02 | |
| Family conflict → PSS—SA (c′) | 0.16 | 0.046 | 0.02 | 0.32 | |
| Indirect d | B | BooLLCI e | BooULCI f | ||
| Family conflict → AISQ → PSS—SA | 0.05 | 0.01 | 0.11 | 0.23 | |
| Total Suicidal Behaviour | |||||
| Direct | b a | p | LLCI b | ULCI c |
|
| Family conflict → AISQ (a1) | −0.22 | <0.001 | −1.21 | −0.328 | |
| AISQ → PSS—SB (b1) | −0.36 | <0.001 | −0.04 | −0.02 | |
| Family conflict → PSS—SB (c′) | 0.04 | 0.018 | 0.01 | 0.08 | |
| Indirect d | B | BooLLCI e | BooULCI f | ||
| Family conflict → AISQ → PSS—SB | 0.08 | 0.03 | 0.14 | 0.66 | |
Note. The b estimates for pathways in which suicidal behaviour (dichotomous) is the outcome variable reflect the increase or decrease in log odds that would be predicted by a 1 unit increase or decrease in Family conflict with all other predictors being constant. AISQ = Assertive Interpersonal Schema Questionnaire; PSS—SI = Suicidal Ideation; PSS—SA = Suicide Attempts; PSS—SB = Total Suicide Behaviour score a Standardized coefficient; b Lower Limit Confidence Interval; c Upper Limit Confidence Interval; d Completely standardized indirect effect; e Bootstrap Lower Limit Confidence Interval; Bootstrap; f Upper Limit Confidence Interval.
Supplementary Materials
The following supporting information can be downloaded at:
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; Villanueva-Blasco, Víctor J 3
; Errasti, José M 1 ; Al-Halabí, Susana 1
1 Department of Psychology, University of Oviedo, 33003 Oviedo, Spain
2 Smoking and Addictive Disorders Unit, Department of Clinical Psychology and Psychobiology, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain
3 Faculty of Health Sciences, Valencian International University, 46002 Valencia, Spain