“JUST SOMEBODY TO LISTEN”: IDENTITY, SCHOOL CLIMATE, AND MENTAL HEALTH AMONG HIGH SCHOOL STUDENTS By Corbin J. Standley A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Psychology – Doctor of Philosophy 2023 ABSTRACT Suicide is a complex yet preventable public health issue impacting youth across the United States. The ways in which identity and school climate impact mental health and suicidality among youth remains relatively underexamined in the literature. In the current study, building on prior quantitative research, I conducted participatory focus groups with high school students as part of a convergent multi-stage mixed-methods project. I leverage intersectionality theory and the phenomenological variant of ecological systems theory (PVEST) to foreground youth voice to inform our understanding of how youth experience the intersections of identity and mental health and suicide, and what resources and support they would like to see in their schools. In the first phase of the study, I conducted two participatory focus groups with 10 high school students at a local high school in mid-Michigan. Students responded to prompts and engaged directly in inductive analysis to code, theme, and categorize their responses utilizing the Youth GO approach. In second phase, I conducted deductive analysis across both focus groups using a priori constructs related to identity, suicide, and school climate, including identity emergence, risk contributors, and stress engagement. Finally, I integrated these findings with the quantitative results from the previous study to further explain and expound on the impacts of identity and school climate on the experiences of mental health and suicidality among youth. Within and across focus groups, students identified both the multifaceted nature and the strength of their unique identities—that they are discovering themselves and their identities in the context of others, which can often create a tension between being authentic and fitting in. Students discussed how assumptions and perceptions from others can influence these experiences, which— when combined with pressures from school, family members, or oneself—can result in feelings of isolation or, in the cases of some students, depression and anxiety. Students identified the need for more accessible and approachable resources in the school, combined with more communication and transparency about what is available. Youth also discussed the need for these resources to be informed by students’ experiences. More than anything, students expressed a desire to be heard and validated: “…that’s honestly all 10-year-old me needed was just somebody to listen.” Taken together, these findings illustrate the need for additional quantitative, qualitative, and mixed-methods research that directly engage youth in conversations about identity, mental health, and school climate. Findings also illustrate the vital need for local, state, and federal legislation that funds research and resources for youth suicide prevention, and ensures the accessibility of such resources. Finally, these findings indicate that more approachable resources and support being available in schools in ways that are convenient, accessible, and equity- and trauma-informed can be affirmative and preventative for youth who are struggling, and may in fact be lifesaving. Copyright by CORBIN J. STANDLEY 2023 Dedicated to my brother David Standley. “Walk on, walk on With hope in your heart And you'll never walk alone.” v ACKNOWLEDGEMENTS I’d first like to express my sincerest gratitude and appreciation to my advisor, Dr. NiCole T. Buchanan, for your much needed guidance, support, and encouragement over the last four years. Your guidance has made me a better scholar who is more authentic and brings my full self to my research and community engagement work. Your support as a mentor and a thought partner has helped me cultivate meaningful and engaging research questions and has helped me become a more well-rounded scholar as a result. Finally, your encouragement through this process has helped me cultivate the career I always envisioned for myself. You helped me to navigate multiple challenges and a full-time job while completing this project, and I’m forever grateful for all I learned along the way. I am also incredibly grateful for my supportive dissertation committee. Ignacio, your thoughtful insights and kind encouragement have helped guide me since I began at Michigan State. I’ve learned so much from you about authentic community engagement and the importance of foregrounding our community psychology principles in my work, and I so appreciate the time and dedication you have given to my multiple projects along the way. Jae, I learned so much from you as a scholar, but also as a teacher. Through your scholarship and by serving as your teaching assistant, I learned how to meaningfully engage students while meeting them where they are—a skillset that has served me very well in this project. Anna, I am so grateful for your willingness to step onto my committee and for your mentorship from a different field and from different institutions over the years. As I’ve found my voice and solidified my place in this field, your approach to community-engaged scholarship and your commitment to quality, public research have served as an incredible example. Of course, this project would not have been possible without my amazing community vi partners who have been with me from the beginning. I am grateful to Eaton RESA for their collaboration. To Kim Thalison, when we met over coffee at Chapelure over six years ago, I couldn’t have expected it would blossom into a years-long collaboration. Thank you for seeing my potential from the beginning, for your trust and support, and for all you do to support the kids in mid-Michigan. To Melea Belton, thank you for your support and guidance over the years. I have learned so much about coalition building and working with youth from you, and your commitment to quality, safe prevention is inspiring. I am also grateful to CMHA of Clinton, Eaton, and Ingham counties for their shepherding of the LifeSavers Coalition and their commitment to engaging the community in youth suicide prevention. Jen Cronkite, thank you for your leadership and example. You lead with kindness and passion while ensuring we keep the kids first in our minds, and our work is better for it. Jody Nelson, thank you for believing in me from the start, and for including me in the work of the LifeSavers. Your dedication to this work and your commitment to quality care have resulted in wonderful advancements in our community. To Joel Hoepfner, thank you for your enthusiasm and support. Your commitment to building bridges and collaborations in pursuit of suicide prevention has improved efforts across the state. To the rest of the LifeSavers Coalition, thank you for your partnership, engagement, and trust. Completing my master’s thesis, comprehensive exam, and dissertation in furtherance of the Coalition’s goals has truly been an honor, and I’m grateful to each of you for the work you do to improve the lives of children and teens in mid-Michigan. To the wonderful students who took part in this study, thank you for your openness and vulnerability and for entrusting me with your stories and experiences. It’s often said that “children are the future,” but the courage you have to share your thoughts and feelings, and the incredible work you do each day to not only succeed academically, but to support your friends vii and loved ones, better your school and community, and take care of yourselves reaffirm that you are making a difference today—right now. Although I could never fully capture all you have to offer, I only hope I have done your stories justice here. To my colleagues at the American Foundation for Suicide Prevention, thank you for helping me to transform my loss into purpose. When I found AFSP as a volunteer nearly 12 years ago, I also found my voice, and in turn, found my career. To my volunteer friends across the country, particularly in Utah and Michigan, thank you for helping me find a family wherever I go, and for helping me to grow not only as a professional, but as a person. To my National and Chapter staff colleagues, thank you for your encouragement and support. I’m so grateful to work with the most dedicated and passionate team there is. To my family. Moving to Michigan six years ago to pursue my PhD was a big step for me, but I know it was a sacrifice for you all as well. Your patience, understanding, and support have meant the world to me. Although the missed vacations and handful of cancelled visits were hard, I do hope you know that they—your sacrifices—have directly contributed to this project. You are partners in suicide prevention, and I am forever grateful for your support and understanding. Finally, to my brother, David. Losing you over 13 years ago changed all of our lives. As I reflect on that and on my career, I hope I’ve become the person and the professional both you and my younger self needed. That is the why behind my work, and what keeps me going. Thank you for continuing to be with me in all I do. “I’m everything that I am because of you.” viii Reflexivity and Positionality PREFACE As it pertains to qualitative research, scholars have been increasingly encouraged to describe their epistemological and methodological beliefs, particularly in terms of how these beliefs impact their research. To that end, at present, I most identify with the interpretative framework of a critical pragmatist such that my focus is on the outcomes of the research and how best to arrive at those outcomes. In short, my approach to inquiry focuses on the problem at hand and how to best solve—or work toward solving—that problem. Ontologically, I view reality as useful and practical. I conceptualize “truth” as what is known at the time, and research into that reality is situated within social, political, and historical contexts (Creswell & Poth, 2018). Epistemologically, I view knowledge as obtained through both deductive and inductive evidence. Moreover, I view knowledge as co-created between the researcher and the participants as both possess skills and knowledge pertinent to the constructs of interest. In terms of positionality, as a gay, Hispanic, first-generation college graduate, I understand the impacts of marginalization on one’s mental health, the role of schools and communities in providing safe and affirming environments for youth, and the need to elevate youth voice in understanding and finding solutions to social issues. Simultaneously, as an often White-passing, cisgender, well-educated man, I also understand the immense privilege I carry as a researcher with the resources of a major research institution. For these reasons, I believe that community-engaged research in which participants and scholars co-create knowledge and solutions is the most equitable and transformative way to conduct research. Finally, my dual identity as a suicide loss survivor and a scholar-activist inform this work. I lost my brother, David, to suicide and this experience has greatly informed my research, ix policy, and activism work. “By emotionally engaging in our work, we can gain a closer and potentially insightful perspective. In other words, this kind of emotional inquiry could be an intellectual resource” (Campbell, 2002, p. 27). I believe this “intellectual resource,” combined with my identities, provides me with an invaluable perspective, a personal connection to the study population, and a passion to bring about change to save lives. A Note on Terminology Researchers and practitioners across academic disciplines and applied sectors who study suicide and its prevention have coalesced into a subfield called “suicidology.” This is the broad, interdisciplinary field to which I will refer throughout the manuscript. In addition, within suicidology, the term “commit” has been strongly discouraged due to (a) its negative connotation and association with crime, and (b) its subtle assignment of moral judgment and perpetuation of stigma. The phrase “died by suicide” is preferred. Similarly, experts recommend against using phrases such as “failed” or “successful” suicide attempts due to their assignment of judgment and subtle implication that dying by suicide is a task that could be thought of as “successful.” For these reasons, “suicide attempt” and “suicide death” are preferred. Finally, throughout the introduction and literature review sections, I will refer to “gender” as well as “male” and “female” when referencing certain statistics related to the prevalence of suicide, as well as research studies that examine differences in outcomes on the basis of identity. Although I utilize the language used in these studies, in most cases, these statistics and studies are actually referring to sex assigned at birth and labeling it as “gender.” This language is exclusionary toward transgender and gender diverse (TGD) individuals. As such, in the results and discussion sections of the current study, I use the language youth themselves listed in open- ended demographic questionnaires. x TABLE OF CONTENTS CHAPTER 1: INTRODUCTION ................................................................................................... 1 Literature Review........................................................................................................................ 2 CHAPTER 2: THEORETICAL BASIS AND CURRENT STUDY ............................................ 10 Intersectionality......................................................................................................................... 10 Phenomenological Variant of Ecological Systems Theory (PVEST) ....................................... 11 Current Study ............................................................................................................................ 12 CHAPTER 3: METHODOLOGY AND ETHICS ....................................................................... 15 Partnership Context ................................................................................................................... 15 Participants and Procedures ...................................................................................................... 16 Youth Generate and Organize (Youth GO) Process ................................................................. 18 Analytic Process........................................................................................................................ 22 Dissemination ........................................................................................................................... 25 Ethics and Safety....................................................................................................................... 26 CHAPTER 4: RESULTS .............................................................................................................. 27 Site and Participants .................................................................................................................. 27 Focus Group 1 ........................................................................................................................... 28 Focus Group 2 ........................................................................................................................... 30 Cross-Group Findings ............................................................................................................... 35 Multi-Stage Integration ............................................................................................................. 37 CHAPTER 5: DISCUSSION ........................................................................................................ 41 How Does Identity Impact Youth’s Experiences of Suicidality? ............................................. 41 What do Youth Want to See Change in their Schools? ............................................................ 44 Community Trauma and Safety ................................................................................................ 46 Limitations ................................................................................................................................ 47 Implications............................................................................................................................... 50 Conclusion ................................................................................................................................ 52 REFERENCES ............................................................................................................................. 53 APPENDIX A: PARTICIPANT SCREENING QUESTIONNAIRE .......................................... 65 APPENDIX B: FOCUS GROUPS PROTOCOL ......................................................................... 66 xi CHAPTER 1: INTRODUCTION Suicide is currently the third leading cause of death among youth ages 14 to 18 in the United States (Gaylor et al., 2023), with suicide deaths in this age group increasing by 56% in the past decade (Curtin & Heron, 2019). Suicide is a complex issue to understand and prevent. In addition to the mental health factors related to suicidality among youth, researchers have found that external stressors (e.g., peer victimization, prejudice, stigma) also contribute to poor mental health and suicidality (Hatchel & Marx, 2018; Hatzenbuehler, 2009; Meyer, 2003; Subica & Wu, 2018). Given the complexity of suicidality, researchers have emphasized the importance of ecological models using multiple levels to inform suicide prevention efforts among youth (Allen et al., 2014; Cramer & Kapusta, 2017; Robertson et al., 2022; Standley, 2020; Standley & Foster-Fishman, 2021). Such models allow researchers to better understand the individual, social, and structural determinants of suicide risk and to design, implement, and evaluate interventions to target those determinants. Building on prior research in mental health and suicide related to identity and intersectionality (Mueller et al., 2015; Opara et al., 2020; Sapiro & Ward, 2020; Standley & Foster-Fishman, 2021), ecological models (Cramer & Kapusta, 2017; Standley, 2020), and context (Edwards, 2021), in this study, I aim to elevate the voices of minoritized youth and leverage the novel integration of theoretical frameworks to better understand young people’s experiences of marginalization and suicidality and what they would like to see change in their schools. This study also informs future research aimed at improving systems- and community- level interventions to prevent youth suicide by (1) highlighting the specific ways in which 1 identity impact youth’s experiences of mental health and suicide, and (2) conveying the changes youth would like to see in schools to feel better supported and affirmed. Literature Review Identity and Adolescence Developmental psychologists have long recognized that adolescence is a pivotal period wherein youth begin to understand themselves and their identity. Building on Piaget’s theory of cognitive development, researchers have described this as “adolescent egocentrism” (Inhelder & Piaget, 1958). Researchers have elaborated on this, discussing adolescents’ tendency to focus on themselves and how others perceive them (Elkind, 1967). This is inextricably linked with the developing cognitive representation of oneself during adolescence—a psychosocial task tied to self-understanding, self-esteem, self-concept, self-regulation, etc. (Galliher et al., 2017). In short, these are formative years during which youth develop a “sense of who they are and what makes them different from everyone else” (Santrock, 2019, p. 128). A key aspect of developing a sense of self is identity formation, which is a quintessential aspect of adolescence (Erikson, 1968). Identity can be described as who a person believes they are as influenced by the integration of self-understanding. During what Erickson (1968) describes as identity versus identity confusion—the fifth developmental stage—adolescents confront new roles, experience themselves in different contexts, explore autonomy, and decide who they are and where they are going (Santrock, 2019). Contemporary theorists argue that identity formation does not end during adolescence, but rather this is the point when physical, cognitive, and emotional development is sufficient to begin identity exploration (Marcia & Carpendale, 2004) and identity resolution may occur in older adulthood as a function of reflection. 2 Often considered a period of crisis developmentally, identity formation in adolescence is rarely straightforward or easy as youth balance a search for autonomy and the need for connection (Erikson, 1968; Santrock, 2019). More recently, theorists have pushed for “a more contextualized understanding of identity development” wherein the impacts of historical, political, and cultural contexts; marginalization; intersectionality; and social roles are considered (Galliher et al., 2017, p. 2011). As Standley (2020) discusses, such considerations are important given that (1) adolescent development and identity formation often differ as a function of gender, race and ethnicity, and sexual identity; and (2) negative outcomes and risk behaviors in adolescence often stem from low self-esteem and increased distress and hopelessness influenced by discrimination, oppression, and victimization. Identity and Risk Behaviors Youth risk behaviors are the risky physical and health behaviors such as alcohol use, drug and substance use, sexual activity, self-harm, and suicidal behavior in which adolescents may engage (Underwood et al., 2020). In the United States, the Youth Risk Behavior Surveillance System (YRBSS) monitors these behaviors among high school-age youth via the national Youth Risk Behavior Survey (YRBS). The YRBS includes survey items measuring injury and violence, tobacco use, alcohol and other drug use, sexual behaviors contributing to unwanted pregnancy and sexually transmitted infections, dietary behaviors, and physical activity (Underwood et al., 2020). Using YRBS data and other regional and national samples, researchers have found disparities in youth risk behaviors on the basis of identities such as race (Ivey-Stephenson et al., 2020; Price & Khubchandani, 2019; Subica & Wu, 2018), gender (Hatchel & Marx, 2018; The Trevor Project, 2023), sexual identity (Caputi et al., 2018; Ivey-Stephenson et al., 2020; The Trevor Project, 2023), and at the intersections of these identities (M. T. King et al., 2018; 3 Standley & Foster-Fishman, 2021). As these researchers have suggested, it is not that these identities themselves are risk factors for youth risk behaviors, but rather the increased victimization, discrimination, and oppression on the basis of identity that serve as risk factors (Hatchel & Marx, 2018; Standley, 2020). Suicidality and Suicide Risk Suicide rates in the U.S. have increased steadily among Hispanic, Black, and American Indian and Alaska Native male adults and among youth and young adults ages 10 to 34 (Curtin et al., 2021). At the same time, suicide attempts have increased among youth since 2009 with increased risk for suicide among youth with minoritized identities (Ivey-Stephenson et al., 2020). More specifically, data suggests that females are more likely to have suicidal thoughts and engaged in suicidal behaviors than males (Miller, 2011); roughly half of transgender youth report having seriously considered suicide (The Trevor Project, 2023); lesbian, gay, and bisexual (LGB) youth are nearly three times more likely to have suicidal thoughts than their heterosexual peers (The Trevor Project, 2021); suicide rates among Black youth have increased by 60% among males and by 182% among females between 2001 and 2017 (Price & Khubchandani, 2019); and Native American and Indigenous youth populations exhibit higher rates of suicide than other nonwhite populations (Sharaf et al., 2009). Experience of Identity. Although more researchers have begun looking at demographic disparities in youth suicide, little research has explored suicide risk among youth at the intersections of minoritized gender, sexual, and racial and ethnic identities (Standley, 2020). In addition, few have examined identity formation and identity experiences among youth as it relates to risk behaviors. That is, there is a need for more research focused on the sociocultural aspects of identity, “what areas of people’s lives matter when defining themselves,” and how 4 identity formation and one’s experiences of identity influence risk behaviors among youth (Galliher et al., 2017, p. 2012). In particular, how context and adversity influence adolescent identity formation and how those experiences impact risk behaviors is underexplored in the literature (Dohrenwend, 2000). Social and Ecological Factors It is imperative to consider the context of adolescence when examining youth risk behaviors. Researchers have demonstrated that social and ecological factors across multiple levels impact suicidality (Cramer & Kapusta, 2017; Reid et al., 2023; Robertson et al., 2022; Standley & Foster-Fishman, 2021) among adolescents. Such factors include social isolation, community understanding, and access to resources. Social Isolation. Since the seminal sociological study of suicide by Émile Durkheim in the 19th century, it has been well-established that social integration plays a vital role in suicidality (Durkheim, 1951). Modern theories of suicide also emphasize the importance social belonging, connectedness, and cohesion (e.g., Joiner, 2005; Klonsky & May, 2015; O’Connor & Kirtley, 2018), as well as discuss the potential negative effects of social integration (Mueller & Abrutyn, 2016). Among youth, there is a “perception that there [is] no one to talk to and that the complexity of trust and isolation [is] compounded further when friends and family [are] seen to be part of the problem” (Gilchrist & Sullivan, 2006, p. 80). This highlights a common theme in the literature regarding youth suicidality: the need for social support across contexts. In particular, youth often report lacking a trustworthy person in whom they can confide (Bourke, 2003; Coggan et al., 1997; Fullagar et al., 2007; Gilchrist & Sullivan, 2006; Miller et al., 2015; Molock et al., 2007). 5 There are three potential explanations for this. First, youth are especially concerned with confidentiality. As Bourke (2003) found, youth are much more likely to seek support when confidentiality is assured. This is of greatest concern when interacting with teachers and school counselors, whom youth often do not trust to maintain confidences. In addition, when youth do confide in someone, it is most often a close friend or peer (Coggan et al., 1997). Second, youth often feel that adults in their lives tend to minimize their feelings and experiences (Gilchrist et al., 2007; Gilchrist & Sullivan, 2006; Molock et al., 2007). For example, one of the most commonly reported antecedents of youth suicide is issues in interpersonal relationships (Bourke, 2003). Youth often find it difficult to articulate their hurt over relationship issues and find that adults fail to take such issues seriously, trivializing the nature of adolescent relationships (Bourke, 2003). Moreover, when such concerns are taken seriously, adults often overreact, unintentionally exacerbating the situation (Gilchrist & Sullivan, 2006). Finally, youth are often perceived as delinquent, disruptive, irresponsible, and/or rebellious (Bourke, 2003; Kerr et al., 2006). As a result, the concerns of youth are often met by dismissive adults, including school counselors, parents, and other authority figures. These thoughts contribute to the prevailing myth that youth risk behaviors are attention-seeking and ought to be discouraged if not ignored completely (Bourke, 2003). Barriers to Resources. Given a situation wherein adolescents are able to navigate the stigmatization of suicide and have their confidentiality concerns assuaged, they are likely to encounter further barriers to obtaining the help they need while in crisis. Particularly in rural communities, access to professional mental health treatment resources are scarce. When they are available, many community members and parents are unaware of them (Gilchrist & Sullivan, 6 2006). In addition, many youth perceive these services as impersonal and unhelpful (Coggan et al., 1997). For minoritized populations such as youth experiencing homelessness, LGB, and transgender and gender-diverse (TGD) youth, appropriately trained and welcoming resources are also scarce or ill-equipped to handle co-occurring issues such as substance use disorders or gender identity issues (Grossman & D’Augelli, 2007; Kidd, 2004). School- and Community-Based Prevention Efforts In light of research highlighting the importance of socioecological contexts, researchers and practitioners alike have discussed the utility of public health approaches to suicide prevention (Cramer & Kapusta, 2017; Robertson et al., 2022). Key aspects of such an approach include (1) moving prevention upstream by implementing programs and initiatives that may stop crises from happening in the first place (Cannon, 2019; Compton et al., 2019; Harris & Rich, 2021; Singer et al., 2019), and (2) implementing such approaches across multiple ecological levels and contexts (Mancini & Huebner, 2004; Sameroff et al., 2003; Standley, 2020). Schools have been identified as one context in which suicide prevention initiatives can potentially achieve each of these two aspects. Such initiatives may provide early intervention for youth who are struggling while also teaching youth valuable intrapersonal and interpersonal coping and social skills that may be protective against risk behaviors (Ayer & Colpe, 2022; Erbacher et al., 2015; Gorzkowski Hamilton et al., 2023; Miller & Mazza, 2018). Moreover, such initiatives can help to boost morale, improve school climate, and create an environment in which youth feel safe and supported (Breux & Boccio, 2019; Reynolds, 2016). For example, in one study of TGD high-school youth in California, researchers found that school belonging mediated the pathway between peer victimization and substance use suggesting that more open 7 and affirming school climates may serve as a protective factor for risk behaviors among minoritized youth (Hatchel & Marx, 2018). Community-Engaged Approach Community engagement is a central component that guided this study. My community- engaged scholarship in this study has two priorities. First, the study builds on previous community-engaged scholarship in the local community supported by an ongoing community- academic partnership (CAP; Drahota et al., 2016) with the Eaton Regional Education Service Agency (Eaton RESA), Community Mental Health Authority of Clinton, Eaton, and Ingham Counties (CEIA-CMH) and the Tri-County LifeSavers Suicide Prevention Coalition (LifeSavers). The second priority is elevating both youth voice and youth agency in the research process by using a participatory qualitative approach. Each of these priorities is further detailed below. Community-Academic Partnerships. CAPs are “characterized by equitable control, a cause(s) that is primarily relevant to the community of interest, and specific aims to achieve a goal(s), and involves community members (representatives or agencies) that have knowledge of the cause, as well as academic researchers” (Drahota et al., 2016, p. 192). These partnerships provide firsthand insight and knowledge to researchers thereby adding relevance to their findings and practicality and actionability to their recommendations. In addition, these partnerships provide communities and agencies with resources (e.g., funding, expertise) they may not otherwise have. Given these advantages, CAPs provide a useful paradigm for conducting community-engaged research that prioritizes community interests and actionable research. Youth Participatory Research and Evaluation. Although the study of youth risk behaviors has attracted increased and warranted attention, a relatively small proportion of 8 researchers have engaged with youth directly to understand their experiences of risk behaviors or how prevention efforts might be most successful (Checkoway & Richards-Schuster, 2003; Jacquez et al., 2013; Stacy et al., 2018; Valdez et al., 2020). Qualitative research with youth has the potential to add needed and valuable richness to extant data while elevating youth voices and experiences. As Hjelmeland & Knizek (2010) argue, such qualitative research is needed in order to refocus on understanding rather than explaining risk behaviors such as suicide. Participatory approaches to such research go a step further by engaging youth in data collection, analysis, and interpretation thereby increasing youth agency and participants’ sense of ownership in the study (Stacy et al., 2018; Valdez et al., 2020). In the current study, I endeavored to elevate youth voice and agency by engaging with youth in a youth participatory action research (YPAR)-informed study using the Youth Generate and Organize (Youth GO) approach (Stacy et al., 2018, 2020). 9 CHAPTER 2: THEORETICAL BASIS AND CURRENT STUDY Although mental health conditions play a major role in youth suicidality (Maimon et al., 2010; Shahtahmasebi, 2013; Stack, 2014), this focus among suicide researchers has resulted in a lack of understanding regarding the impacts of social identity, context, and social-ecological factors on suicidality, particularly among youth (Standley, 2020). Moreover, although researchers in suicidology have made progress in disaggregating data and examining risk behavior disparities, such efforts have largely failed to (1) account for the intersections of minoritized identities, (2) consider the interpersonal, contextual, and systemic factors contributing to risk, and (3) consider how these multi-level factors intersect with social identities to inform our understanding of risk and prevention. To fill this gap, I conducted a qualitative study building upon a previous quantitative study (Standley & Foster-Fishman, 2021) as part of a convergent multi-stage mixed-methods design (Creswell & Plano Clark, 2011; Fetters et al., 2013). This differs from a mixed-methods sequential explanatory design wherein sequential methods are used within the same study (Ivankova et al., 2006). Intersectionality Despite the glaring disparities in outcomes among youth, there is a dearth of research examining how the intersections of these identities might exacerbate risk behaviors among youth. The critical theory of intersectionality provides a useful lens through which to examine these disparities in a multiplicative way (Dubrow, 2008). Consistent with the discussion of identity above, intersectionality recognizes that the combination of multiple minoritized identities manifests at the individual level of experience as influenced by macro-level systems of power and oppression (Bowleg, 2012; Crenshaw, 1989; Galliher et al., 2017). Although more research on intersectionality and youth suicide is necessary, researchers have found that (1) 10 youth with multiple minoritized identities are more likely to experience suicidality and engage in suicidal behaviors (Bishop et al., 2022; Bostwick et al., 2014; Garnett et al., 2014; Standley & Foster-Fishman, 2021; Wiglesworth et al., 2022), and (2) protective factors for suicide (e.g., social support) may differentially impact intersectionally minoritized youth (Standley & Foster- Fishman, 2021). Phenomenological Variant of Ecological Systems Theory (PVEST) Emergence of identity is also a key component of the phenomenological variant of ecological systems theory (PVEST; Spencer et al., 2006; see Figure 1). Beginning with a focus on African American populations and evolving over time (Cunningham et al., 2023), PVEST asserts that identities combine to inform one’s sense of self-efficacy and lay the groundwork for future behaviors and coping mechanisms. These behaviors and coping methods culminate in adverse (unproductive) or productive life outcomes, including suicidality. Identity formation, in combination with the remaining components of PVEST, accounts for influence from contextual and multi-level systemic factors. Such a focus accomplishes the goals of the phenomenological approach and advances the current research on risk behaviors among youth in two major ways. Firstly, it drastically Figure 1. Major components of the Phenomenological Variant of Ecological Systems Theory (Spencer et al., 2006). reduces the focus on the individual level of analysis by directly illustrating the developmental 11 process of adolescence within and between contexts and systems (Swanson et al., 2003). Secondly, it allows for the investigation and understanding of both unique and collective experiences that are paramount to the phenomenological research process by examining the interactions between identity, culture, and experience across contexts (Cunningham et al., 2023; Hjelmeland & Knizek, 2010; Spencer, 2008; Spencer et al., 1997, 2006; Wertz, 2011). These advancements also serve to meet the aims of the study by elevating the voices of youth to better understand how the intersections of minoritized identities impact young people’s experiences of suicidality, and what youth see as necessary components of a safe, supportive, and affirming school climate. Current Study In examining youth identity and risk behaviors, in the current study, I integrated a contemporary conceptualization of youth identity (e.g., Galliher et al., 2017) with the intersectional and phenomenological theoretical underpinnings discussed above. First, this integration recognizes how youth have unique experiences of identity, including stress and resilience (Galliher et al., 2017; Wertz, 2011). As a result, this conceptualization views adolescents as whole persons as opposed to different aspects of the self. Consistent with Bronfenbrenner's (1979) ecological systems theory and its phenomenological variant (Cunningham et al., 2023; Spencer, 2008; Spencer et al., 1997, 2006; Wertz, 2011), this integration also encompasses the roles of culture, social roles, life domains, and everyday experiences that combine to inform individuals’ identities. Overall, this theoretical integration informed by developmental and community psychology allows for the expansion of typical approaches to research on suicide by (1) assessing factors outside the individual allowing for a more dynamic and culturally responsive 12 approach, (2) accounting for identity formation and developmental processes in the design of school-based initiatives, and (3) centering the perspectives of youth in discussing school climate and programs. I also aimed to elevate youth voice and experience by applying a participatory approach to data collection and analysis utilizing the Youth GO approach (Stacy et al., 2018). Given the PVEST theory guiding the project, the population of interest, and the aims of the research, such a participatory method was an appropriate strategy for the study. This approach allowed me and the community partners to better understand the unique experiences of young people related to suicidality and risk behaviors, and the desire to inform school climate (Israel et al., 2008). In particular, stakeholder engagement, co-learning, capacity building, and an aim toward turning data into action will be embedded in the current study. From these theoretical perspectives, in the current study, I endeavored to better understand young people’s experiences of suicidality to inform school climate and program changes. The phenomenological qualitative study had two aims. The first aim was to better understand how the intersections of identities (e.g., race and ethnicity, sexual identity, and gender identity) impact young people’s experiences of mental health suicidality. Focus groups with students from a local high school utilizing the Youth GO approach included questions guided by intersectionality theory and the key components of PVEST, including social identity, power and oppression, risk behaviors, and social support (Spencer, 2008; Spencer et al., 1997, 2006). The second aim was to understand what youth feel they need changed in their schools to feel more supported and affirmed. A two-phase integrated analytic approach rooted in phenomenology was applied. The first phase involved stages two, three, and four of the Youth GO process during which youth participants themselves generated, coded, and themed their data 13 in an inductive analysis process. The second phase involved a combination of a priori components guiding a deductive analysis of emergent themes (i.e., characteristics from PVEST). These components included identity emergence, net vulnerability, and stress engagement. Finally, findings were used to develop and convey youth’s recommendations for school climate and program changes. Two primary research questions guided the study: 1. How does identity impact youth’s experiences of suicidality? 2. What do youth want to see change in their schools to better support and affirm them? 14 CHAPTER 3: METHODOLOGY AND ETHICS Partnership Context Since the fall of 2017, I have been working with Eaton RESA, CEIA-CMH, and the LifeSavers on numerous projects focused on youth substance use and suicide prevention in the tri-county area. These projects have included secondary data analysis and reporting, community presentations, strategic planning, grant writing, facilitated trainings and discussion, and primary data collection, analysis, and dissemination. The current study is Study IV of this partnership. Study I was a quantitative study focused on the analysis of existing data sets including the Michigan Profile for Healthy Youth (MiPHY) and nationally available aggregate suicide incidence data (see Standley, 2018). Study II built on the findings of Study I by using secondary data from the MiPHY survey to examine how marginalization, intersectionality, and social support shape youth suicide risk (see Standley, 2019). The theoretical basis for Study II was published in Death Studies (Standley, 2020), and the empirical findings were published in Suicide & Life-Threatening Behavior (Standley & Foster-Fishman, 2021). Study III was conducted in response to the needs identified by Study II and included a systematic review of school-based suicide prevention programs (see Standley, 2021). This partnership provided the community relationships, resources, and youth engagement necessary to conduct Study IV, described in more detail below. More specifically, Eaton RESA’s current goals, connections to local high schools, previous engagement with youth in these schools, and staff resources provided the access, trustworthiness, and reputation required for successful community-engaged work with youth. 15 Participants and Procedures The current study received approval on July 13, 2022 following a Full Board review from the Social Science Institutional Review Board (IRB) at Michigan State University (Study ID 00007038). Sampling and Recruitment Given the composition of the three counties of interest, I sampled at both the school and individual level. School-Level Sampling. For the purposes of this study, I used a convenience sampling method to select high schools within the tri-county area. This was done using existing relationships among the researcher, the district, and Eaton RESA. That is, I contacted schools for which existing positive relationships were present. Unfortunately, school-level sampling was significantly hindered by a multitude of environmental and sociopolitical factors, including the COVID-19 pandemic, mass shootings at Oxford High School and Michigan State University (both local to the area of interest), false flag shooting alerts at Okemos High School and other area schools and organizations, increased demands on school faculty and staff, and a sociopolitical climate resulting in increased hesitancy from administrators, staff, and parents to broach issues of identity and social-emotional learning. Due to these challenges and extenuating timeline issues associated with the IRB, just one school (Sunrise High School—a pseudonym) ultimately agreed to participate in the study. Individual-Level Sampling and Recruitment. I then used a purposive, referral-based sampling method to obtain participants for the study. First, using lists of supportive and potential faculty obtained through relationships with the Michigan Department of Education’s Safe Schools Project, the Michigan Organization on Adolescent Sexual Health, and Eaton RESA, I 16 reached out to faculty advisors for school-based youth groups (e.g., Peer Assistance Leaders (PALs), Choices Program participants, and Gay-Straight Alliances (GSAs)) to gauge interest in participation. Students who met each of the eligibility criteria were then approached for participation by the faculty member and had the research process explained to them. Those who assented were given an informed consent form to be signed by a parent or guardian to allow participation in the study. Those who consented completed a brief questionnaire (see Appendix A) to prompt initial thinking about identity among participants and gather information about focus group participation. Participants A total of 10 students participated across two focus groups at Sunrise High School (a pseudonym for a local high school in a tri-county area mid-Michigan). Participants ranged in age from 14 to 18. Five participants self-identified as white, five self-identified as male, and eight self-identified as straight or heterosexual. Six participants disclosed experiencing thoughts of suicide at any point, and two disclosed having attempted suicide at some point in the past. Procedures I used a semi-structured focus group protocol (see Appendix B) based on the Youth GO (Stacy et al., 2018) model to (1) allow participants to discuss their feelings and experiences openly, and (2) provide youth with agency and ownership as part of the research process. In order to investigate youths’ experiences and how these experiences are influenced by intersectionality and identity formation, open-ended questions building on phenomenological tradition, and (Spencer, 2008; Spencer et al., 1997, 2006) in particular, was used. PVEST focuses on both what youth experience and how they experience it and conceptualizes these experiences within an ecological framework. 17 Focus groups took place in a classroom at Sunrise High School in January of 2023. They were conducted privately between myself and youth in the classroom, along with two licensed and certified prevention specialists present should the need for support or crisis services have arisen. Focus groups were audio recorded and lasted approximately 90 minutes each. Youth Generate and Organize (Youth GO) Process I conducted data collection by implementing the Youth Generate and Organize (Youth GO) participatory research approach (Stacy et al., 2018, 2020). Youth GO is a process that authentically engages youth in data collection, analysis, and interpretation. Building on youth participatory action research (YPAR; e.g., Foster-Fishman et al., 2010; Vaughn et al., 2011) and participatory evaluation (Chen et al., 2010; London et al., 2003), Youth GO provides youth with agency and ownership as partners in the research process in a developmentally appropriate way. Given the participatory goals of the community partners, the comparative time and cost savings (Stacy et al., 2020), and my own desire to elevate the lived experiences of youth in research, Youth GO was an ideal approach for the current study (Stacy et al., 2018; Wertz, 2011). Youth GO can be easily facilitated by community members and is less resource intensive than traditional focus groups (Stacy et al., 2020). This was particularly useful for the current project given Eaton RESA’s objective to build staff capacity while increasing youth engagement and voice. The Youth GO approach engages four to eight youth in a focus group session during which they generate, organize, and interpret their perspectives and themes around given Figure 2. Youth GO: A Five-Step Approach to Gathering Youth Perspectives (Stacy et al., 2018). 18 issues. The protocol consists of five steps in which youth co-establish rules and boundaries, generate data, learn qualitative analysis skills, code and theme data, and discuss findings (see Figure 2 above). Stage 1: Climate Setting Stage 1 of the Youth GO approach emphasizes climate setting and rapport building: Co- establishing group norms and expectations with youth participants (Stacy et al., 2018). During this stage, I introduced myself and the goals of the focus group, and students co-created a set of group rules to guide discussion and establish group dynamics. We also discussed the importance of confidentiality and privacy, emphasizing that the research team will maintain confidentiality by ensuring all recordings and notes are secured, and emphasizing that although we cannot guarantee other focus group participants will maintain confidentiality, its importance will be repeatedly conveyed. We then discussed a rapport-building icebreaker question (What is something about yourself that you like talking about that you wish people asked you about more?) to ensure students were comfortable with each other and the facilitator. This question allowed for open discussion and let the students choose what they would like to talk about. Following the icebreaker, I led students through a salient circles activity designed to help them “recognize identities that are central to their sense of self,” the intersections of those identities, and the multi-level factors that impact their identities (Buchanan, 2020, p. 400). During the salient circles activity, students illustrated their identity using concentric circles to represent their most salient identities, their intersections, and their meaning. Students then took turns explaining their diagrams while discussing the identities they chose and how they are related to one another. 19 See Figure 3 below for an example (not from a study participant). Students then reflected on their experience of the activity, their observations, and potential meanings behind those observations (Buchanan, 2020). The illustrations themselves were not used for data collection purposes, but rather, the goals of this activity were to (1) Figure 3. Example of salient circles diagram. familiarize students with the concepts of identity and intersectionality, (2) encourage students to think about their identities, and (3) continue building trust and rapport among students. Stage 2: Generating During Stage 2, prompts were revealed on flip chart paper and read out loud to the students. At this point, students were encouraged to reflect individually and write their responses on sticky notes and stick them onto the flip chart (Stacy et al., 2018). During this process, students were encouraged to ask questions and I provided clarification and probing questions. After all responses were collected, I led a discussion during which students reflected on the group’s responses and clarified as needed. Table 1 below lists the prompts related to the substantive areas of interest described above. 20 Table 1. Stage 2 focus group prompts. Topic Identity • What does intersectionality mean to you? • How do you feel you are treated at school? Prompts Suicidality • How has the way you are treated impacted your mental health? o In what ways do you think this treatment is based on your identity? o In what ways do you think this experience was influenced by your identity? School Climate • What are things you wish your school had to help you be successful? • What would make you feel safer at school? Stage 3: Organizing The organizing stage (Stage 3) had two aims: (1) To guide youth in organizing and coding data, and (2) to support youth in organizing and categorizing the data to which they contributed in Stage 2 (Preskill & Russ-Eft, 2005; Stacy et al., 2018). To achieve the first aim, students participated in a candy sorting game as a developmentally appropriate method for introducing data organization skills. This game included theme creation and organization based on my instructions. This process was then adapted and applied to the data provided by students in Stage 2. Students then worked in smaller groups of two to three to place their organized responses onto color-coded paper to signify themes within each question. Stage 4: Selecting In Stage 4, students extended what they learned in Stage 3 to identify categories for the themes that have emerged across questions (Stacy et al., 2018). Students then discussed meaningful names and definitions for these categories. This resulted in overarching themes organizing the data provided in Stage 2. Stage 5: Debrief and Discussion During Stage 5, I led a discussion in which students reflected on their participation in the Youth GO process as well as their experiences (Stacy et al., 2018). Following this debrief, incentives in the form of Amazon gift cards were given to each participant. Contact information 21 for the study team was provided via a copy of the informed consent form in the event that participants had additional questions or concerns. Analytic Process The two phases of analysis for the current study were inductive (within-group) and deductive (cross-group). The inductive analysis phase employed the Youth GO approach described above. Given the study’s theoretical basis in phenomenology (i.e., understanding youths’ lived experiences of marginalization, suicidality, and risk behaviors), the qualitative analysis process outlined below maps well onto the phenomenological approach described by Creswell and Poth (2018) for inductive analysis, as well as the thematic analysis steps outlined by Braun and Clarke (2006) for deductive analysis. Within-Group Analysis Analysis began during the first focus group. As youth proceeded through the stages of Youth GO, analysis began at the “narrow units of analysis” broadening to larger themes and then categories that summarized the data (Creswell & Poth, 2018, p. 77). Table 2 below describes how this phenomenological analytic plan maps onto Youth GO in more detail. Note that the table chronologically begins at the analysis-related stages of Youth GO. MAXQDA was used to find and code quotes and flip-chart statements to the themes identified by students during the focus groups. Quotes were chosen based on authenticity and representativeness while ensuring they were illustrative and succinct (Lingard, 2019). To enhance readability and respect students’ dignity and meaning (Corden & Sainsbury, 2006), quotes were edited for clarity by removing false starts, filler words, or grammatical errors, or by adding punctuation. 22 Table 2. Youth GO as mapped onto phenomenological inductive analysis processes. Creswell & Poth (2018) Steps Youth GO (Stacy et al., 2018) Generate themes from the analysis of significant statements Develop textural and structural descriptions based on significant statements Report the “essence” of the phenomenon by using a composite description Stage 2 – Generating Stage 3 – Organizing Stage 4 – Selecting Cross-Group Analysis At the conclusion of the focus groups, I used deductive analysis with a priori constructs related to PVEST (i.e., identity emergence, net vulnerability, and stress engagement; Spencer, 2008; Spencer et al., 1997, 2006). This process aided in understanding youth’s experiences across focus groups and coalescing them into collective experiences where warranted. Given that scholars have described thematic analysis as theoretically independent (Freeman & Sullivan, 2019; Joffe, 2012), the use of thematic analysis within this study was appropriate. The deductive analysis phase followed the process for thematic analysis outlined by Braun and Clarke (2006). In step one, to further familiarize myself with the data, I used the flip chart responses, themes, and categories generated by the youth as the primary documents for thematic analysis. Since these materials were generated with my facilitation in the room, familiarity with the data was inherent. In steps two and three, the a priori constructs discussed above guided my analysis. MAXQDA was used to find and code quotes and flip-chart statements to these constructs and their relevant themes. Table 3 below defines these constructs of interest as well as how they map on to the study’s underlying theory (PVEST). 23 Table 3. Deductive analysis codes, operationalization, and PVEST components. Themes Codes Operationalization Social Identity Treatment Strengths Suicidal Ideation Suicide Attempts y t i t n e d I y t i l a d i c i u S Demographic social identities as self-reported by youth (e.g., race/ethnicity, gender, and sexual identity) and their intersections. The experiences of overt or covert treatment based on one’s social identities. The strengths and positives youth describe as a function of their identity. The thoughts and cognitions of engaging in suicidal behavior that one might experience. Previous experience attempting suicide or engaging in forms of self-harm. l o o h c S Resources for Success e t a m i l C Safety Existing or desired tools, resources, and/or policies that might promote wellness and success. Sense of safety in school and on the way to and from school. PVEST Components (Spencer, 2008; Spencer et al., 1997; 2006) Emergent identities Net stress Protective factors Life stage outcomes Life stage outcomes Net vulnerability Reactive coping processes Net vulnerability In step four, I reviewed the themes and refined them accordingly. This process was followed by step five in which final cross-group themes were named and defined based on both the a priori codes presented in Table 3 and on the refinement process in the previous step. Data Integration Figure 4. Data integration process. As described above, the current study functions as a continuation (Study IV) of work conducted in partnership with Eaton RESA, CEIA-CMH, and the LifeSavers. In combining results from this study with previous quantitative work, I aim to provide a fuller picture as to how identity and context impact risk behaviors among youth (Hjelmeland & Knizek, 2010). As such, following the analysis and interpretation of the qualitative findings, results were used to further explain the findings from the initial quantitative study in a 24 convergent multi-stage mixed-methods design (see Figure 4; Creswell & Plano Clark, 2011; Fetters et al., 2013). Dissemination Following the defense and approval of this dissertation, dissemination of these findings will occur in four ways. First, a formal community report will be developed as a fourth volume to the data reports developed for the previous phases of the project. This comprehensive report will include an executive summary, methods and analysis, findings, and implications for research, policy, and practice. Secondly, a community presentation of the findings will be presented to the LifeSavers as a follow up to the presentation of the quantitative findings. This presentation will be a shortened version of the community report and will last 20-30 minutes. Thirdly, a two-page brief will be created that summarizes the findings of the study, incorporates youth voice, and presents recommendations to local school administrators and legislators for school- and community-based prevention for youth. Finally, the results will be submitted as articles for publication in academic journals and used to inform academic conference presentations. 25 Ethics and Safety The confidentiality and privacy assurances afforded by the informed consent process can present challenges in research involving high-risk participants. In particular, asking questions of this nature in a focus group setting may elicit the disclosure of serious suicidal crises or self- injurious behavior. Whether to keep such disclosures in confidence or to disclose it to professionals or parents or guardians is a major ethical concern in youth risk behavior research (Fisher, 2010). To that end, most professional codes of ethics and guidelines permit the disclosure of such information provided not doing so would be construed as harmful to the participant. In accordance with these guidelines, and given the research team’s role as mandated reporters, every effort was made in this study to attend to the safety and well-being of the participants, including the presence of certified prevention specialists. No disclosures of current suicidal thoughts and/or self-injurious behavior were made by participants in either focus group. Licensed prevention specialists were also on hand in case students expressed a need for support or crisis services. Confidentiality All audio recordings were transcribed, and aliases were assigned to participants so as to maintain confidentiality. Only the research team members have access to the audio recordings, transcripts, and data, which are stored on a secure server meeting all FERPA and IRB requirements for data confidentiality. Data were digitally recorded and transcribed, and all recordings and transcriptions are stored on a secure server with access granted only to specific, encrypted computers. Recordings have been removed from the recording devices. All recordings, transcripts, and data files will be destroyed three years after the study has concluded. 26 Site and Participants CHAPTER 4: RESULTS Sunrise High School is a larger public high school of about 1,700 students in grades nine through twelve located in the tri-county area around Lansing, Michigan. Ten students who serve as Peer Assistance Leaders (PALs) at Sunrise High School participated across two focus groups in January of 2023. PALs students are selected to serve as peer mentors for their classmates through an application and interview process and attend a three day training focused on mentorship and peer assistance, as well as community service. Participants ranged in age from 14 to 18. Data from an open-ended demographic questionnaire indicate that most participants self-identified as white and straight, with half self- identifying as male, half self-identifying as female, and two identifying as bisexual. Six participants disclosed having had thoughts of suicide at some point in their life. Table 4 below provides a description of the students within each focus group. Table 4. Description of focus group participants. # n Race/Ethnicity Gender Identity Sexual Orientation Previous Suicide Attempt Previous Suicidal Thoughts 1 5 Slovak White Indian White Asian 2 5 White White White White Hispanic Male Straight Male Straight Male Straight Straight Female Woman/Female Straight Straight Male Straight Female Bisexual Female Straight Female Bisexual Male No No No No Yes No No Yes No No Yes Yes No No Yes Yes Yes Yes No No Previous Treatment for Suicidality No No No No No No Yes Yes No No 27 Focus Group 1 Theme 1: Individuality Throughout the focus group, students commented on individuality and uniqueness both in terms of identity, and in terms of their experiences at school and with peers. Appropriately, the students labeled an overarching theme of “individuality,” describing it as how identity uniquely applies to each person. Two subthemes emerged throughout the discussion, including code switching and coexisting identities. Students discussed adjusting their personalities and their most salient identities depending on who they are with and where they are: “…certain personality traits of you will be stronger, whereas others won't. Or vice versa. Like, around your parents or around different peers”. Students described this as being advantageous—being able to show different aspects of one’s personality. As one student said, “I have different aspects of what makes me me, and it's okay to not show every single aspect of you around everybody all the time.” Students also discussed the complexity and overlapping nature of their identities (“…different identities coexisting together […] I exist as a daughter and a cousin at the same time, you know?”) and how that complexity makes everyone unique (“…everyone's different and how no one person is the same as another”). Moreover, students described their own agency in determining their identities: “Individual people define themselves differently, you know, like different categories.” Students discussed this as a strength related to identity. Theme 2: It Depends Across topics and questions, students often remarked that “it depends.” This also arose during the organizing and selecting phases, with both smaller groups selecting—and the larger group agreeing—on an overall theme labeled “it depends,” describing responses to questions 28 related to both how they are treated at school and how that treatment impacts their mental health. “It depends” captures these responses well as students discussed the way they are treated and its impact on their mental health as dependent on one another as well as social standing (“… if you have a lot of friends, people are gonna be like, ‘Oh, I'm gonna go talk to her,’ less because of you as an individual, but more as if, ‘oh, well, if other people like her, then I'm gonna like her.’”). Through the facilitated discussion, students also went further, connecting how they are treated and their mental health to their identity. As one student said, …the way you feel you're treated at school influences your identities, but your identities also influence how you're treated at school if that makes any sense […] The way I'm treated at school, if it's more positive, I tend to stick to those people or stick to that activity. And then that, therefore, goes and influences my identity. Theme 3: Success and Safety Students identified a third theme as “success and safety”. Although posed as separate questions, students described them as related. A related subtheme was the need for free time. Students discussed the demands of homework, advanced placement classes, pressure around college and a career, and balancing it all: “I think that's another area that my mental health suffers from is, you know, having so much to do that I don't have time for myself.” “By having so much homework, you're limiting their extracurricular activities, you're eliminating sports, any form of exercise in any form, or self-care. Students also discussed the then-recent shooting at nearby Oxford High School along with false flags at other schools, and their impact of sense of safety and hypervigilance (“You never know who’s next to you”). Whereas some students discussed the need for increased 29 security, others pointed out that the presence of law enforcement may not be a comfort to everyone: At the middle school, when the Oxford shooting happened, we had two police officers there. And the people were freaking out [...] they were static. Everyone was on edge and […] letting them know it’s secure, yes, that's a comfort for some people. But for some people, that's a stressor because they're people with guns in their school. Students also identified specific recommendations for increasing student success and safety, including more college resources and information prior to senior year (“One thing I wish our school had was more information about college and scholarships and that it was more easy to access”) and increased accountability for instances of racism and homophobia (“If we report someone being racist, the administration doesn't do anything […] They'll be like, ‘oh, yeah, we'll talk to them’ […] How does that ensure that that problem won't happen?”). Focus Group 2 Theme 4: Self Students in the second focus group identified a broad theme of “self” to capture ideas around intersectionality. Subthemes included the multidimensional nature of identity (“…being complex or not just part of one group, but multiple pieces.” “…being a part of many different groups.” “…showing everyone’s multifaceted…”), uniqueness (“It’s just everything about somebody and what’s unique to them and what makes them true to themselves.”), and how these traits may serve them in the future (“Colleges want these kids to be super well rounded”). Discussion around this theme was positive and supportive, with students describing their uniqueness—and others’—as admirable. In particular, students discussed identity more as self- 30 affirming than as socially assigned or constructed. As one student wrote, “I decide who and what I want to be.” Theme 5: Assumptions and Perceptions Students also discussed being perceived based on a single trait or hobby and often feeling judged and overlooked as a result of being misperceived: I'm kind of misunderstood because some people think I just do it just for the recognition, which is not true […] I already know some people are like, ‘Oh, he's totally gay’, which is not true. You don't judge a person based on that. The theme of “assumptions and perceptions” describes these feelings well. As one student wrote, “People always assume I am fine because on the outside, everything appears to be fine when it might not be.” This resonated with the group and, as one student said “My big one is that it appears that everything looks fine and like I have all my ducks in a row…”). This theme also included feelings around expectations, which all five students either wrote or spoke about—both expectations from one’s self (“I always have had high expectations no matter what I’m doing for myself”) and from others (“When it comes to leadership roles, I feel like a lot of weight is put on my shoulders when some people expect greatness…it's a lot when other people rely on me.”). Students also described those expectations as sometimes hindering their enjoyment of activities they participate in, such as band, athletics, or student leadership: “I think everybody feels like they're supposed to be doing all of these different things. And maybe we do enjoy them. But then there's also an added pressure that's maybe outside of our love for what we do.” 31 Theme 6: Negative and Positive Pressure These assumptions, perceptions, and expectations were described as coming from peers, teachers, and parents alike. Students identified a theme of “positive and negative” related to the pressures they often face. While acknowledging some of the pressure being self-imposed, students indicated that this pressure impacts their mental health. As one student confided: …when they make their assumptions of like, ‘oh, everything is perfect, and everything is great,’ [… ] I feel like maybe my mental health is—it's not a good day for me. But I'm like, ‘well, these people were seeing what I want them to see. They think everything's perfect, so I don't really need to do anything.’ Because if they think it's perfect, then it must be. Other students expressed similar thoughts: “If you didn't do good, then you weren't classified as good enough. And I think that's kind of what led to my anxiety and depression because I got diagnosed with anxiety and depression towards 6th or 7th grade.” “I have been diagnosed with depression and also general anxiety…everything kind of played into that […] I've always had high expectations for myself, and then other people around me have judged me.” Despite the pressure, students also discussed their resilience. As one student said: It also led me to grow as a person and surround myself with those who are good in my life, know when to stand up for myself, and know when to step back. And then knowing my worth and knowing that I deserve to have people who love me to be surrounded around me. Theme 7: Mental and Physical Needs In discussing what would help them be more successful, students discussed a multitude of things they categorized as “mental and physical needs.” This theme largely encompassed mental 32 health resources and social support, as well as more practical recommendations. In particular, students discussed feeling as though the adults in their life do not take their experiences and feelings seriously: “I feel like adults sometimes don't think that younger people can experience real emotions without having to go through something huge.” As one student stated, recalling an experience with their grandparents, “I would talk about how something was upsetting to me, or frustrating to me, or how I was stressed and they're like, ‘Well you don't know what stress is.’ And adults often say that to kids.” Students discussed how this perception from adults in their lives impacts how they view mental health resources and support at school: “I feel like a lot of people who are making the decisions to make these outlets for kids are under the assumption that we can't feel big feelings” “You can go talk to your counselor if you're feeling this way or if you're feeling anything, you can go talk to them. But I never felt comfortable enough to go up and actually say something.” Overall, students discussed how student-informed, approachable resources could make a big difference in their academic and personal lives. In describing what would make them feel more comfortable using resources at school, students wrote “A more welcoming environment,” “more presence from counselors,” and “mental health outlets that didn’t feel judgmental.” This was elaborated on in discussion: “It’s crazy to think about that—how impactful it could be to have just somebody to listen because that's honestly all 10-year-old me needed was just somebody to listen. And I just felt so unheard.” In discussing what more approachable resources might look like, students described fixing the one-and-done approach often taken when it comes to mental health in schools: “You can say at the beginning of the year if there's a club fair […] you have a little flyer or something and it says that’s there. I don't think that's enough.” Students described addressing this through 33 increased availability of resources (“Right now we have counselors, but you can never get an appointment […] When you're gonna have a really bad day, and you can't wait for your appointment in two weeks with your therapist”). Peer Support and Connection. Students also described the importance of peer support and connection. In particular, students described participating in the focus group itself as being helpful in normalizing the conversation around mental health: “I feel like things like this, where you all come together and—we all come from different backgrounds […] it's just having conversations and making that more normal.” This sentiment was echoed by other students as well: … you're doing a study to see what kids actually have to say. I feel like if there was more input on what we actually have to think and not what adults think that we have to think it would be way better. But when you have something like this, when you listen to what's actually going on with your peers, and it's a chance to relate to each other rather than it just seeming like a surface level of actually getting to know why people relate to this, and, challenging your own assumptions a little bit more. Despite this feeling, students also discussed the limitations of peer support. Although they found sharing their experiences and feelings to be helpful, they also addressed how peer support may not be the right avenue for every issue. As one student said, I wouldn't want to sit and talk to someone my own age, tell them my problems, and then they would tell me how to fix them. Because then it would make me feel like an awful person like, ‘Oh, they know how to fix it. They have all their things together. And look at me—I'm in the same situation, but I don't…’, it just would make me feel unvalued. 34 Cross-Group Findings A Priori Themes Across both focus groups (FG1 and FG2), the three a priori themes of identity, suicidality, and school climate were evident, comprised of seven codes across the three themes. Identity. The three codes (social identity, treatment, and strengths) within the theme of identity emerged across both focus groups. Primarily, students discussed personality traits and relationships as important aspects of their identity, building on social identities such as race or sexual orientation to create a whole self. As one student put it, “I'm a brother, son, cousin, you know all those things. An athlete occasionally […] I'm a good friend. Again, human, student, and Christian as well.” (FG1). Students described identity as being multi-faceted (“not being categorized into one group” (FG2), “Many parts of one whole” (FG2)), and as informing how they are treated at school (“People value stuff I do” (FG1), “As a role model and leader for others” (FG2). Students also discussed the strengths of their identities—in particular, their own autonomy and agency in deciding who they are and what that means: “I’m free to define myself any way I want” (FG1). One student articulated this particularly well in stating that identity is about “labeling who you are without really labeling yourself” (FG2). Suicidality. Although discussion about suicide specifically was relatively rare, a few students across both groups talked candidly about their experiences with suicidal thoughts and behaviors, including suicide attempts. As a student in FG1 said, “I've never seriously considered taking my own life. But I have wondered ‘what would it be like if I wasn't here? Would anyone notice? Would anyone care?’” Another student directly addressed how more approachable resources in school may have been preventative: “But I feel like if my school had more approachable options for me […] I might not have tried to take my own life when I was in the 35 sixth grade” (FG2). In an abundance of caution, each of these students was connected with a prevention specialist following the conclusion of their focus group. Multiple students across both groups discussed their mental health more broadly. As described above, students in FG1 described the impacts of environment and isolation on their mental health, and students in FG2 disclosed diagnoses of depression and anxiety. Taking time for self-care and its importance for mental health was also discussed: “I need time to prioritize my own mental well-being my physical well-being and my sleep” (FG1), “I value my free time and I… a big part of me is self-care, like doing what's best for me and what's good for me” (FG2). School Climate. Although the discussion of school climate differed within each group, both touched on resources for success and safety. A commonality across these codes was the need for more awareness of available resources and supports. This was related to both safety (“When the Oxford shooting happened, that was so close to home, you know? Yeah. It was scary. And I didn't know what our school was doing about it to make that not happen at our school” (FG1)) and transparency (“…through more frequent communication and transparency,” “…just having that transparency like there is someone in it just making it more well known […] I feel like it's just something that you need to be more clear about more often.” (FG2)). Overall, students described feeling invalidated and not listened to at school. In particular, students discussed feeling as though their experiences—be they relationship troubles, social pressures, academic pressures, etc.—are often not taken seriously by their teachers or school staff: “ It’s […] ‘Oh, you're a kid.’ […] And no one takes it seriously. So that's something that we need to do better” (FG1). 36 Participant Reflections Regarding the experience of participating in the focus groups themselves, students described the process as enjoyable (“I really enjoyed it. I think it’s a good topic that a lot of people need to hear about”; FG1), safe (“I’m glad we had the group we had…That comes back to the safe environment. You can have that conversation without feeling like you sound really rude”; FG1), and grateful (“It was kind of nice. I think it was a great opportunity. I’m really glad I participated”; FG2, “I feel like I should be giving you a gift card”; FG2). In particular, they described the experience as a valuable opportunity to talk with and learn from one another. As one student put it, “This is a really fun way to learn about others. People should do this more often. Like, instead of doing icebreakers, they should do this. It’s a little more personal, but that’s a good thing”(FG1). Multi-Stage Integration In Study II of this project (Standley & Foster-Fishman, 2021), we analyzed secondary data from the 2015-2016 wave of the Michigan Profile for Healthy Youth, which is how the YRBS is administered in Michigan. In a sample of 5,058 high school-age youth in this same tri- county area, using t-tests, we found that youth with minoritized identities in terms of race and ethnicity, gender, or sexual identity were more likely to report higher levels of suicidality (defined using a suicidality scale comprised of three items assessing suicidal ideation, plans to attempt suicide, and previous suicide attempts). Moreover, using regression models, we found that youth with multiple, intersecting minoritized identities (i.e., gender, race and ethnicity, and sexual identity) were more likely to report higher levels of suicidality. We also examined the unique and compounding impacts of family-, school-, and community-level social support (defined both as opportunities for prosocial engagement and 37 rewards for prosocial behavior; Bond, 2000). Each unique source of social support was significantly associated with lower suicidality scores among youth. Moreover, when family and school supports were combined, this was associated with the lowest suicidality scores in the models, suggesting that social support across multiple contexts may be more protective for youth. Finally, we also found that family support in particular mitigated the relationship between intersectionality and elevated suicidality scores in the sample, suggesting that social support at the family level may be even more important for youth with intersecting marginalized identities. Results from the current study may serve to address two major questions from these findings. Youth Identity First, why might youth with minoritized identities be more likely to report higher suicidality scores? The sample in the current study was relatively homogenous with most students identifying as white and straight. However, those students with minoritized identities did discuss the impact that false assumptions and being perceived based only on a single identity. As one student said, “I’m bisexual, but it just doesn't make me who I am and […] I'm not gonna talk about feelings with other guys because they assume—well, that’s why I don’t have many guy friends” (FG2). Other male students in the groups echoed this sentiment—that it can be challenging to discuss feelings with and form deeper friendships with other boys in school based in part on societal expectations of men: …it's so much harder to almost make friends…build deep relationships with people because the main acceptable part that you're showing is really only such a small part. And if you…just stray so far from the social ‘what's okay’ and stuff […] I think that it's kind of hard to make so much deeper relationships because getting into the deeper things that people feel or talk about is—it seems like makes you seem a certain way (FG2). 38 Overall, students across focus groups emphasized the importance of authentic connection with one another, as well as the role of connections with teachers and school staff, and how expectations and assumptions based on their identity may inhibit such connections. Social Support Second, what are the key components of social support that may be associated with lower suicidality? Students discussed the role of peer support in their mental health. In particular, one student discussed their journey through a tough period and how their relationships have evolved since: I feel like some of the lower point in my life and my mental health especially have been from when I have new experiences that were negative I guess […] Like friend troubles or I transferred schools in sixth grade. And for a long time, I didn't have a lot of friends. People didn't talk to me. I was kind of shy and quiet […] That especially goes to show you how things change (FG1). Similar discussions were had in both focus groups. As another student wrote, reflecting on their experiences with anxiety and depression, “[My diagnoses] led me to prioritize the good people in my life and surround myself with love and what I deserve” (FG2). In general, students described the bidirectional relationship between their friendships and their mental health, and how important prioritizing quality friendships wherein deep conversations can happen are. Students also discussed the challenges of developing and maintaining friendships, and how these relationships are often influenced by their hobbies and the groups they find themselves in: “I feel like you see so many extremes in high schools, because some people like art…then you're automatically grouped with the with people who have that extreme and their tendencies and all that which is […] not appropriate or fair” (FG2). “Yeah, most of my friends are through 39 sports, school, classes, clubs. If I wasn't in that club with that person, I saw that person randomly on the street, would we be friends? Would they like me? Do they like me?” (FG1). Students discussed that more opportunities to informally share and discuss their experiences with one another could be helpful. In particular, while reflecting on the focus group, students highlighted how sharing their experiences and feelings in a safe and non-judgmental way can assuage feelings of isolation and may help foster connections: “Yeah, it's great hearing what other people […] I feel like it's good hearing because sometimes I think ‘I'm crazy for how I feel,’ but then hearing how other people feel too—It makes me feel seen and so it was nice” (FG2). Students also identified school-level social support as a key factor, highlighting the need for staff that are approachable and can listen in a non-judgmental way: “But I feel like if my school had more approachable options for me, because I might not have had those in my own house, to feel comfortable enough to talk about those kinds of things” (FG2). Students highlighted their desire to talk about what they are feeling without the focus immediately being on solving the problem: “I feel like a lot of […] push, all these things to have like an immediate solution and being okay with it not being a solution, but helping in any way […] we try to have as resources are to find the solution […] usually that's not what happens” (FG2). “…trying to find quick solutions aren't the thing; just talking about it. I think it's way more helpful than being like, ‘Oh, do this’” (FG2). 40 CHAPTER 5: DISCUSSION Understanding how youth think about identity, experience and discuss mental health, and perceive and access resources is imperative for developing, implementing, and evaluating effective and equitable suicide prevention resources in schools. Despite this, youth voice and qualitative research remain underutilized methods for informing such resources. In the current study, I used participatory focus groups with 10 high school students to understand how identity impacts mental health and suicide among youth, and what youth would like to see in their schools in terms of resources and support. The inductive themes students identified and the deductive themes I identified map well onto the theories underpinning this study: intersectionality theory and PVEST. In particular, how students discussed their identities—and how they understood the interrelated nature of their mental health, stressors, and outcomes such as mental health—resonates with existing literature. Moreover, through these themes, students identified practical recommendations for their schools, including fostering a more welcoming environment, implementing more approachable resources, and building an understanding among students and staff of “how impactful it could be to have just somebody to listen” (FG2). How Does Identity Impact Youth’s Experiences of Suicidality? Both within and across focus groups, students saw identity, mental health, and school climate as intrinsically and recursively linked. They described their identities as informing how they are treated, the way they are treated informing their identities, the reality of different salient identities for different interactions, and how each of these factors impact their mental health, including thoughts of suicide and suicide attempts. These findings fall into two overarching categories: (1) identity and intersectionality and (2) mental health, stressors, and outcomes. 41 Identity and Intersectionality Overall, students in this sample viewed intersectionality and identity as less related to social identities (e.g., race and ethnicity, sexual identity, or gender identity) and focused more on their roles in others’ lives and how they view themselves as a person. There are three likely explanations for this finding. First, high school-age students may not view their racial, sexuality, or gender identity as the most salient aspects of their identity, choosing instead to highlight their connections, interests, and personality traits. Alternatively, the concept of intersectionality (particularly its multiplicative and multi-level nature; Crenshaw, 1989; Dubrow, 2008) may be a bit complicated and nuanced for high school students to fully grasp and respond to, particularly when given only a brief definition and in the context of a short activity. Finally, school climate (both overall and where the focus groups took place in particular) may have inhibited students’ willingness to share about these particular identities. As Aldridge et al. (2016) found in a sample of over 4,000 Australian high school students, there may be a “link between school climate and the development of students’ self-identity” such that students who reported a strong sense of belonging in school were more likely to report positive ethnic and moral identity (p. 11). Additional research on this potential connection in U.S. high schools might further clarify this relationship. Students’ understanding and discussion of identity in this study also aligns with psychological developmental literature. Students in this study discussed themselves and how others perceive them as key aspects of their identity—what developmental psychologists define as egocentrism (Elkind, 1967; Inhelder & Piaget, 1958). Moreover, students described a tension between being authentically themselves and fitting in—between autonomy and connection. This 42 echoes developmental psychological theory emphasizing finding this balance as a key milestone in the developmental process of adolescence (Erikson, 1968; Santrock, 2019). Mental Health, Stressors, and Outcomes As stated above, students viewed their mental health as interconnected with their identity and the school climate. This aligns well with PVEST as a theoretical underpinning of this study. As a human development theory, PVEST views “diverse individual-contexts interactions as worthwhile contributors to the sources and pathways of both productive and less productive coping processes, which, in turn, result in patterned life stage-specific outcomes” (Spencer, 2008, p. 700). As supported by these findings, youth who do not have strong social support from their family or friends may be negatively impacted by risk factors including mental health conditions or social stereotypes and their related assumptions, the combination of which is termed “net vulnerability” (Spencer, 2008; Spencer et al., 2006). In particular, many youth find that adults minimize their feelings and invalidate their experiences (Gilchrist & Sullivan, 2006; Molock et al., 2007), which may contribute to risk and vulnerability. In addition, this case may be worsened by elevated expectations and pressure, increasing one’s “net stress” level. How one manages this stress is termed “reactive coping processes,” and they may be adaptive or maladaptive. As the students in this study identified, the interactions between and combinations of these three constructs—vulnerability, stress, and coping strategies—inform identity development—what Spencer (2008) calls “emergent identities.” Recall the student from FG1 who said, “The way you feel you're treated at school influences your identities, but your identities also influence how you're treated at school.” Ultimately, this then both productive and unproductive outcomes for youth (Spencer, 2008; Spencer et al., 1997, 2006). Students described growing from challenging 43 social and mental health situations, learning to value self-care and surround themselves with supportive and affirming friends. Overall, “the bidirectional and recursive components” of PVEST are well-supported by the current study (Cunningham et al., 2023, p. 526). Not only are youth’s experiences of support, stress, coping, identity, and outcomes interrelated, but they also understand and discuss these components with each other as being interrelated. In particular, students identified the role the school environment plays in their identity formation and mental health. This echoes prior research suggesting that a positive, supportive school environment is protective against suicide risk for youth across demographic groups (Harder et al., 2023; Standley & Foster-Fishman, 2021). What do Youth Want to See Change in their Schools? Students in this study were vulnerable enough to share their experiences and feelings in the hopes of informing change at their school. Within and across focus groups, I identified four overarching recommendations for schools to develop and implement resources for students, including accessibility, approachability, communication, and student input. Findings from this study will inform the development and launch of a new school-based health center (SBHC) at Sunrise High School, which will include a full-time mental health professional. Researchers have found that effective SBHCs led to positive short- and long-term academic and health outcomes among youth (Arenson et al., 2019; Gruber et al., 2022; Love et al., 2019). In particular, SBHCs with increased availability of mental health resources in particular are associated with lower levels of depressive symptoms, suicidal ideation, and suicide attempts among students compared to other schools (Paschall & Bersamin, 2018). Moreover, SBHCs with integrated physical and mental healthcare can address often co-occurring physical and mental health issues and eliminate 44 the access barriers many families face (Mueller et al., 2022). As such, these recommendations have the potential to create an SBHC that meets the needs of students while also improving outcomes at Sunrise High School: • Accessibility: Students described a scarcity of resources and long wait times for appointments. Resources, including both practical resources and dedicated staff, should be accessible throughout the school day as well as for a period of time before and after school. In addition, adequate staffing ensures students are able to make an appointment within a reasonable amount of time. • Approachability: Students described feeling uncomfortable utilizing resources and feeling judged if they do utilize them. Resources and staff that are non-judgmental, welcoming of diverse identities and experiences, and focus on listening first will ensure students are comfortable accessing and utilizing them. • Communication: Students described a “one and done” approach where resources are communicated at the beginning of the school year and are not mentioned or encouraged thereafter. Consistent, transparent, and year-round communication about available resources, where they are located, and how to access them will build trust and sustainability. • Student Input: Students described feeling as though their thoughts, feelings, and ideas are not taken seriously. The use of a student advisory group to inform the development of a school-based health center and future resources will ensure they are authentically meeting the needs of those they intend to serve. Above all, students desire to be heard and validated. Beyond just practical problem- solving, students want someone to listen to what they are feeling, recognize that their feelings are 45 authentic and valid, and respond with care. This, combined with effective mental health resources, can result in an SBHC that is trusted, accessible, and sustainable. Community Trauma and Safety An unanticipated finding from this study was students’ discussion of physical safety as related to their mental health and success. Undoubtedly, the unique context around this study informed this finding. More specifically, the context of this study shifted significantly throughout its course. School shootings at Oxford High School and Michigan State University, as well as false flags for shootings in the area weighed down administrators and faculty, community organizations, and youth themselves with many struggling to keep up with their minimum responsibilities. As students themselves identified, these traumatic events impact mental health (Abdalla et al., 2022; Lowe & Galea, 2017; Neria et al., 2008), school climate (Mallett, 2020; Syvertsen et al., 2009), and sense of safety (McCuddy et al., 2023; Yang et al., 2023) among students. Across the country, school shootings have increased by over 300% since 2000, with 93 shootings at public and private elementary and secondary schools in the United States in 2021 (Irwin et al., 2022). This reality is front-of-mind for students as they walk into school each day. Students in this study discussed feeling unsafe, unsure, and uninformed with regard to the security precautions in place and, as a result, described a state of hypervigilance. Not only is this reality tied to the mental health of students, but how school shootings are addressed and reported on—particularly around the mental health of the perpetrator—may increase stereotypes and result in students being reluctant to seek help for themselves (Gregory & Park, 2022; Silva & Capellan, 2019). 46 Limitations In both this study and the study on which it builds, my intention was to assess and understand the unique experiences and feelings of local high school students and ultimately inform change efforts in the tri-county area. As such, although these findings may inform recommendations beyond mid-Michigan, I did not intend these findings to generalize to other settings. In short, these findings simply represent what is true for these students at this school at the time of the focus groups. That said, due in large part to the issues described above, sampling and recruitment were particularly challenging in the present study, resulting in a small sample size of 10 students. As a result, I was not able to reach meaningful saturation on the themes. Although the two focus groups provided rich, quality data and illuminated many valuable insights—particularly when converged with previous quantitative findings—further qualitative research into these themes would be of benefit to the field. The small sample size also resulted in a sample that was relatively homogeneous in terms of race, ethnicity, and sexual identity. Although representative of the youth demographics of the county in which the study took place, my initial intention was to highlight the experiences of minoritized youth—particularly intersectionally minoritized youth—to better understand the unique impacts of identity and school climate on their mental health. Although sampling and recruitment challenges made this impossible, the current study does add to our understanding of these constructs. Still, researchers should endeavor to understand how intersectional marginalization impacts mental health and suicidality among youth. An additional sample limitation may be related to volunteer bias. Because students were required to get parental consent to participate in the study, it may be that students who participated were those most likely to have supportive and affirming parents or guardians. As a 47 result, findings may be limited to students with a similar home life—a vastly different sample from many LGB and TGD youth across the country. In particular, these findings may not extend to high school-age youth whose home life is not afforming of their identity or whose parents or guardians are uncomfortable with discussions of identity and mental health. As such, researchers should endeavor to examine the intersections of identity, mental health, and school climate through participatory studies with youth in order to better understand how these constructs are related for youth with unsupportive families. Youth GO is designed to gather youth perspectives in a participatory way to inform program development and improvements (Stacy et al., 2018). As such, it was an appropriate methodology for the current study. However, although the participatory nature of this study undoubtedly increased the authenticity and accuracy of the findings, from a research perspective, there are two limitations to this approach. First, the inductive analysis students engaged in during the focus groups was limited both by the prompts presented and by students’ understanding of the constructs and issues—limitations also discussed by Stacy et al. (2018). Students were not extensively trained in inductive analysis or qualitative coding and theming. As a result, the themes they identified often related more to the specific words used than the broader ideas that were generated. Second, to accommodate faculty, student, and school scheduling, only 90 minutes were available for each focus group. As researchers have identified, such limitations can inhibit relationship building between the researcher and the students, and among the students themselves (Jardine & James, 2012). In addition, we were often unable to spend sufficient time on each of the prompts in an effort to get through the entire protocol. Time constrictions likely limited conversation and resulted in more limited findings. 48 I utilized a convergent multi-stage mixed-methods design in this project. As such, the limitations of the quantitative study on which this study builds extend to this project. In particular, the age of that data, the cross-sectional and secondary nature of the data, missing data and listwise deletion techniques, the narrow application of intersectionality, and the collapsing of minoritized identities for analysis limit the generalizability and understanding of longitudinal effects of the variables on one another (see Standley & Foster-Fishman, 2021 for a fuller discussion of these limitations). These combined with the small sample size of the current study results in findings that are specific to mid-Michigan and, in particular, the students of Sunrise High School. Future mixed-methods research that utilizes longitudinal data, participatory methods, and leverages the expertise of youth would also be of tremendous benefit to the field. Institutional and Structural Barriers In addition to the context around community trauma, there were significant institutional and structural barriers to conducting this research. In particular, Michigan State University’s IRB—as is the case across many universities—had misconceptions about the potential risks of conducting suicide-related research among youth. This resulted in a six-month delay in protocol approval and pushed study recruitment back by nearly nine months. These misunderstandings, while well-intentioned, are based largely in stigma and ultimately limit our understanding of suicide and its prevention. More specifically, the IRB had concerns about discussing suicide with youth assuming it may increase their risk. However, an overwhelming majority of research demonstrates that there are little to no risks related to asking youth about their suicidal thoughts and behaviors (Blades et al., 2018; DeCou & Schumann, 2018; Gould et al., 2005; Jorm et al., 2007; Law et al., 2015; Polihronis et al., 2020), and that adverse events in such studies are exceedingly rare (Kuiper et 49 al., 2019). Overall, the benefits youth receive from participating (e.g., decreased suicidal ideation; feeling heard, supported, and validated; stigma reduction; resource awareness; etc.) outweigh any potential risks that might come with participating in such research. Moreover, asking these questions of youth is imperative to understanding the scope of the issue of suicide and how it can be prevented. Not asking suicide-related questions in qualitative research also poses a significant ethical problem for the field, and has implications for suicide research more generally (King, 2016). As such, suicide researchers have an obligation to educate their institutions in order to advance meaningful science toward prevention. As Gibson et al. (2013) state, It is perhaps understandable that [IRBs] veer towards paternalism when dealing with suicide. At the same time, the reluctance to engage in qualitative research in this area also perhaps reflects the wider societal reluctance to talk openly about suicide, ironically one of the reasons why there is such a need for qualitative research in order to facilitate understanding and to give those who have suicidal feelings a voice (p. 25). In short, those experiencing suicidal ideation have the same research participation rights as others and hearing their voices and understanding their stories is pivotal to designing, implementing, and evaluating effective prevention strategies. Implications The current study has the potential to refocus suicidology research and practice more holistically to capture the individual, social, and contextual factors relevant to youth suicide. More importantly, in examining each of these areas, we learn more about their interactions and interdependencies thus illuminating critical intervention and prevention points. In particular, findings from this study have implications for research, policy, and practice. First, this study 50 adds to a scare literature utilizing mixed methods approaches to understand how identity, social support, and school climate impact mental health and suicidality among youth. I encourage researchers to continue investigating this area while foregrounding youth voice and experience. Beyond these constructs, research examining community awareness and understanding, stigma surrounding mental illness, and mental health conditions among youth have the potential to increase our understanding and inform prevention. Overall, research investigating the ecological, social, and individual factors associated with youth suicide has the potential to create a more holistic and comprehensive understanding of the issue. These findings also illustrate the need for local, state, and federal legislation that (1) funds qualitative and participatory research studies to better understand suicide and its prevention, (2) provides for both evidence-informed resources and ample trained mental health providers and support staff in public schools, and (3) enforces mental health parity so such resources can be accessed and utilized by those most in need. As Mueller et al. (2022) state, “Schools need the funds and the freedom to invest resources in the ways that will best meet the needs of their local student bodies” (p. 16). The methods used in this study also highlight the need for youth voice and engagement in policymaking itself. Engaging youth in advocacy efforts may increase their sense of ownership in their community and in the political process (e.g., Standley, 2021a). Findings from the current study also have the potential to inform interventions aimed at curbing youth suicidality using a whole child approach. Such interventions should encompass support from multiple sources as well as training on warning signs, safety planning, and mindset shifts among participants. For example, a holistic intervention might incorporate familial, peer, and community support (e.g., Standley & Foster-Fishman, 2021); train teachers and school staff 51 on recognizing the warning signs of suicide and how to safely intervene (e.g., Stickl Haugen et al., 2022); and focus on building resiliency, self-esteem, and self-efficacy among youth (e.g., Shahram et al., 2021; Valois et al., 2015). Such an intervention is more likely to be successful if each of these domains is addressed. In doing so, schools can also increase families’ likelihood to see schools as a resource when their child might be struggling (Mueller et al., 2022). In speaking with youth directly and understanding their unique and collective experiences, findings from the present study have the potential to inform intervention designs like those described above. Conclusion The current study adds to a series of studies conducted with community partners to understand youth suicide risk and prevention in a tri-county area in mid-Michigan (Standley & Foster-Fishman, 2021). Over the last six years, this multi-study project has informed theory development (Standley, 2020), coalition strategic plans, grant applications, school improvement plans, and state policy change (Standley, 2021a). This project has also informed research regarding how race and structural factors (Robertson et al., 2022) and sexual identity and policy impact youth suicide risk and prevention, as well as how research can inform practical solutions for suicide prevention in healthcare, schools, and communities (Gorzkowski Hamilton et al., 2023). Taken together, my program of research has helped illuminate school-, community-, and systems-level efforts toward youth suicide prevention. These findings extend this program of research by prioritizing community engagement and youth voice and directly informing change efforts at Sunrise High School. My hope is that this program of research continues to inspire community-engaged scholarship and foster change to improve the lives of youth across the country. 52 REFERENCES Abdalla, S. M., Cohen, G. H., Tamrakar, S., Sampson, L., Moreland, A., Kilpatrick, D. G., & Galea, S. (2022). Mitigating the mental health consequences of mass shootings: An in- silico experiment. EClinicalMedicine, 51, 101555. https://doi.org/10.1016/j.eclinm.2022.101555 Aldridge, J. M., Ala’i, K. G., & Fraser, B. J. (2016). Relationships between school climate and adolescent students’ self-reports of ethnic and moral identity. 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There are not right or wrong answers to these questions—simply answer each truthfully. Only members of the research team will see your responses, and each questionnaire will be kept confidential and secure. If you have any questions or concerns, please feel free to reach out to a member of the research team. For Research Team Use Only Participant ID: _________________________________________________________________ Identity 1. How would you describe your racial or ethnic identity? ______________________________ 2. How would you describe your gender identity? ____________________________________ 3. How would you describe your sexual identity? _____________________________________ 4. Are there any other aspects of your identity you would like to us to know about? If so, please write them here: _____________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Suicidal Thoughts and Behaviors 6. Have you ever experienced thoughts of suicide?  Yes  No  Prefer Not to Say 7. Have you ever attempted suicide?  Yes  No  Prefer Not to Say 8. Have you ever been in treatment for suicidal thoughts or behaviors?  Yes  No  Prefer Not to Say Focus Group Participation 8. In which of the following focus groups would you be most comfortable participating (select all that apply)?  With any other teens from my school  With other teens who share my identities (please describe): _________________________________ _________________________________ _________________________________ 65 APPENDIX B: FOCUS GROUPS PROTOCOL Step 1: Climate Setting (25 Minutes) MATERIALS • Nametags (x30) • Markers • 8.5 x 11 paper (x30) • Salient Circles example • Youth consent form • Pens • Prepared flip charts: o Social Contract o Parking Lot PROCESSES Introductions Ask students to complete a nametag as they enter. Once all students are present, the facilitator introduces themselves to the group: • I am a student researcher from MSU working and I have been working with local schools for a number of years. I am interested in understanding your experiences and what you would like to see change at your school. Overview & Purpose Then discuss the purpose, goals, and time commitment for the focus group: • Today, I am interested in gathering your experiences in your school and how your school might be able to better serve students. This information will be used to help inform programs your school might implement. The activities today should take about two hours. Consent Next, discuss informed consent and assent process. • Describe consent process. • • If youth wish to participate, have them complete consent form. If youth do not wish to participate, dismiss them back to school staff or guardians. Social Contract Next, the engage with youth to create a social contract/community agreement. • Introduce the Social Contract: A Social Contract is a tool to guide group interactions and will help facilitate our work together today. • Allow time for youth to present suggestions for the Social Contract. • As ideas are presented, write them on the Social Contract flip chart paper. o Example: Each person’s experience or perspective is valid. We all have different perspectives, but don’t downplay ideas because you don’t agree. • Once the Social Contract is complete, everyone should agree to the contract by signing. 66 Parking Lot • Introduce the Parking Lot: The “Parking Lot” is a space for noting questions or concerns that may be outside the scope of the conversation, yet important to our group goals. • Throughout our group conversation, you may add ideas here or I may direct you to do so to keep us on track. • At the end of our activities, we will be sure to revisit any items on here as needed. Rapport Building The facilitator will ask a rapport building question to engage youth in back-and-forth discussion and build trust and norms for the group. • What is something about yourself that you like talking about that you wish people asked you about more? Salient Circles • Introduce Salient Circles activity: The goal of the salient circles activity is to think about your identities and what they mean to you. This activity will also help us all get to know each other and build some trust with one another. • Instructions: Today we’re going to be talking about identities and what they mean to us. We all have many identities that can be thought of as combined or intersected. Intersectionality is a word we use to describe multiple different identities, such as gender and race. During this activity, you will each draw a diagram illustrating what identities in yourself are important to you. For example, this is my salient circles diagram: it illustrates that I am a suicide researcher as well as a community psychologist and Latino man. Each of these identities is important to me in different ways. There is no right or wrong way to think about or draw your identities. Simply draw circles on your paper, overlapping them where it makes sense to you, and drawing bigger circles for the identities that are most important to you. Some examples might be Black, bisexual, sibling, child, student, or any other number of identities you hold. Again, there is no right or wrong way to draw your identities. • Group Discussion: Now that we’ve all drawn our salient circles, let’s talk about what they mean. Once all activities are complete, proceed to the next step. 67 Step 2: Generating (30 Minutes) MATERIALS • Pens • Post-it notes • Flip chart paper with prompts: o What does intersectionality mean to you? o How do you feel you are treated at school? ▪ In what ways do you think this treatment is based on your identity? o How has the way you are treated impacted your mental health? ▪ In what ways do you think this experience was influenced by your identity? o What are things you wish your school had to help you be successful? o What would make you feel safer at school? PROCESSES Introduce Activity Introduce the group discussion activity: • Today we’re going to be discussing a few questions that I have prepared and posted around the room. First, I will ask the question and then you can write your response to the question on sticky notes. Write as much detail as you can, and if you need any help, just ask! • This is about your opinion and there are no wrong answers. • After everyone has responded individually, we will process each question with a group discussion. Process Prompts Then, process the questions one at a time using the following steps: • Present and read aloud first question. • Provide time for questions and clarifications. • Provide time for participants to record individual responses on post-it notes. • Participants place responses on flip chart paper. • Lead a group discussion about the responses. • Add in any additional responses or clarifications that emerge in the discussion onto the sticky notes. Use probes to prompt group discussion, such as: • Does anyone disagree? • Has anyone had a different experience? • Why do you feel that way? • Can you talk about that more? • Does anyone else have something they want to add here? • Did we miss anything? Once all activities are complete, proceed to the next step. 68 Step 3: Organizing (20 Minutes) MATERIALS • Bags of assorted candy • Colored sheets of paper (6 per group) • Pens PROCESSES Candy game Introduce the next activity: • Now we are going to play a game! • Once we have learned how to play the game, we will apply what we learned. Explain game rules: • Imagine that your team owns a new store that sells candy. Your team buys four bins to organize the candy for the customers and must come up with a name for each bin. The names should be clear enough so that customers who can’t see the candy still know what type of candy is inside each bin. • Distribute small bags of assorted candy and colored paper for categorizing the candy. • Allow time for youth work on the task, helping only when needed. Then, explain the next task: • Now imagine that two of your bins broke. Organize the candy again, using only two bins and come up with a name for each bin. The names must still be clear enough so that customers who can’t see the candy know what type of candy is inside each bin. • Distribute two new sheets of paper to represent the bins. • Allow time for the youth to work on the new task, helping only when needed. Data organizing: Themes Once youth are finished with the candy game, describe the next task: • Now we are going to take what we just learned about how to create groups with candy and apply it to our answers to the questions we just discussed. • We are going to organize the responses into meaningful groups, and create names for the groups, which are called “themes” Provide the youth with one flip chart sheet (containing the questions and responses) and additional sheets of colored paper. Allow time for youth to organize the responses for each question into meaningful themes, helping only when needed. Repeat this process for each flip chart sheet until all questions and their responses have been organized into themes. Once all activities are complete, proceed to the next step. 69 Step 4: Selecting (15 Minutes) MATERIALS No new materials needed PROCESSES Data organizing: Categories Describe the next activity: • You just worked to group the question responses, which we can also call “themes.” • Now we are going to create big groups for all of the questions and responses. This will help us to determine what we think is most important to capture everything we discussed today. These groups will be called “categories.” Lead a group discussion to determine the categories. • Allow the youth to present suggestions. • Have the group to come to a consensus using thumbs up/thumbs down process. • If youth find this task challenging, use the following prompts to guide the group discussion: • What is the most important thing we discussed today? • Can you group any of these themes together? • What would be a good name for these similar responses? • What themes are the most important to you? • It sounds like there was a lot of discussion about _____today. Is this important to include? Cross checking Once a few categories are selected, leads a cross checking process to make sure that all categories align with at least one theme and that all themes are included within the categories. • For example, start with the first question: What does youth voice in decision-making mean to you? • Review the themes created for this question. • Then for each theme, ask: “What category does this map on to?” (More than one category can be selected.) Write the relevant categories on the colored sheet for each theme. If no categories align with a particular theme, a new one may be created. • • Throughout this process, the names of categories may be changed/adjusted if necessary. • If a category does not align with any particular theme, it may be removed. Once all activities are complete, proceed to the next step. 70 Step 5: Debrief & Discussion (10 Minutes) MATERIALS No new materials needed PROCESSES Closing Discussion Leads a brief discussion about how the activities went: • That concludes our activities today, you all did such a good job working together to help us understand youth decision-making within Community Schools. • Ask a few probing questions about how they felt the activities went, such as: o How did it feel participating today? o What did you like about these activities? o What didn’t you like about these activities? What could be better? Debrief Conclude the meeting with a debrief: • Thank you so much for participating in the activities today to discuss decision-making within Community Schools • The discussion and information provided today will be directly used to understand and improve decision-making opportunities for students. • Provide details about next steps and upcoming Community Forum. • We really appreciate your thoughtfulness and engagement during the activities today and the time you committed to being here. We could not do this work without you! • Distribute incentives. This concludes all group activities. 71