Shame-Focused Cognitive Behavioral Therapy For Reducing Suicide Risk In Adolescent Psychiatric Inpatients (SF-CBT)

Shame will be measured using the External and Internal Shame Scale (EISS), which assesses two core dimensions of shame as a transdiagnostic emotion: external shame and internal shame. Both the subscales and total scores of the EISS demonstrate good internal consistency and concurrent validity and are significantly associated with depressive symptoms (Ferreira et al., 2022).

Coping or defensive strategies toward shame have a significant impact on psychological functioning. The Compass of Shame Scale (CoSS) will be used to assess four coping styles individuals employ when experiencing shame: attack self, withdrawal, attack others, and avoidance. Studies have shown that the CoSS has good reliability and validity, with internal consistency coefficients ranging from 0.74 to 0.91 across subscales (Elison et al., 2006).

The Alexian Brothers Urge to Self-Injure Scale (ABUSI), which measures the severity of urges to engage in NSSI. The ABUSI shows good internal consistency, test-retest reliability, sensitivity to change, as well as convergent, predictive, and incremental validity (Washburn et al., 2010).

The Deliberate Self-Harm Inventory (DSHI), which assesses deliberate self-harming behaviors. The DSHI demonstrates high internal consistency and good structural, convergent, discriminant, and test-retest validity, supporting its reliability and validity as a measure of deliberate self-harm (Gratz, 2001).

Depression will be assessed using the Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al., 2001). A study of 10,933 school-aged adolescents in Hong Kong found that the PHQ-9 demonstrated good model fit under a single-factor model with correlated item pairs and maintained measurement invariance across gender and age groups. The PHQ-9 exhibited good internal consistency (>0.84) and showed expected correlations with anxiety (>0.77), self-esteem (<-0.57), and perceived control (<-0.56). Therefore, the PHQ-9 is suitable for assessing and comparing depression severity among adolescents of different genders and age groups (Leung et al., 2020).

The Generalized Anxiety Disorder-7 (GAD-7) scale will be used to assess the severity of generalized anxiety disorder (GAD) symptoms. Research indicates that the GAD-7 has good internal consistency and demonstrates strong convergent validity with measures of anxiety, worry, depression, and stress. Moreover, the scale is highly sensitive to symptom changes during brief intensive cognitive-behavioral therapy (CBT). Overall, the GAD-7 shows excellent internal consistency, convergent validity, and sensitivity to change within this sample (Kertz et al., 2013).

The Chinese version of the Insomnia Severity Index (ISI-C) will be used to evaluate the severity of insomnia in clinical patients. Studies have shown that the ISI-C has good reliability and validity, with a Cronbach's α of 0.804 and a test-retest reliability of 0.887 (P < 0.01). It also demonstrates good structural and predictive validity. When the cutoff score is set at 10.5, the ISI-C achieves 84.0% sensitivity and 92.3% specificity (P < 0.01) (Bai et al., 2018).

A self-developed Adolescent Irritability Scale will be used, comprising four dimensions: self-injurious irritability, object-destructive irritability, interpersonal irritability, and self-directed irritability. Preliminary results indicate that the scale has good reliability and validity, and related psychometric research is currently in publication.

The Chinese version of the Rosenberg Positive Self-Esteem Scale (RSES) will be used to measure levels of self-esteem. The RSES shows good item discrimination across different samples. Internal consistency reliability (Cronbach's α) ranges from 0.83 to 0.89 in college, adult, and military samples, while the four-week test-retest reliability in high school students is 0.76, indicating good structural validity (Chen et al., 2015).

The Instability of Self-Esteem Scale (ISES) will be used to evaluate fluctuations in self-esteem levels. Findings suggest that the ISES has satisfactory internal consistency and test-retest reliability. Moreover, its low correlation with the RSES indicates that the two instruments measure relatively independent psychological constructs. Distinct correlation patterns between ISES, CES-D, and BPI further support its discriminant validity (Chabrol et al., 2006).

The Self-Compassion Scale-Youth Version (SCS-Y) will be used to assess self-compassion among early adolescents. It consists of six dimensions: self-kindness, self-judgment, mindfulness, isolation, common humanity, and over-identification. The SCS-Y demonstrates good test-retest reliability and construct validity, with expected correlations with mindfulness, well-being, life satisfaction, depression, psychological resilience, and achievement goal orientation (Neff et al., 2021).

The 2-Way Social Support Scale (2-Way SSS) will be used to evaluate both the giving and receiving of social support, distinguishing two primary types: emotional support and instrumental support. It consists of four core dimensions: (a) giving emotional support, (b) giving instrumental support, (c) receiving emotional support, and (d) receiving instrumental support. Research indicates that the scale has a sound structural framework, strong item generalizability, and applicability across various contexts. Findings support its reliability and validity as a measure of social support (Shakespeare-Finch \& Obst, 2011).

The Patient Health Questionnaire-15 (PHQ-15) will be used to assess the severity of somatization symptoms. In this study, three additional symptoms-stomach pain, palpitations, and limb numbness-are included to provide a more comprehensive evaluation of somatic symptoms. Each item is rated from 0 ("not bothered at all") to 2 ("severely bothered"). Cutoff points are defined as 5 (mild), 10 (moderate), and 15 (severe somatic symptoms). Findings support the PHQ-15 as a simple, self-administered tool with good reliability and validity for screening and monitoring somatization severity in clinical and research settings (Kroenke et al., 2002).

The State Hopelessness Scale will be used to measure the level of hopelessness. This instrument has demonstrated high construct validity and incremental validity (Dunn et al., 2014).

The Chinese version of the Difficulties in Emotion Regulation Scale (DERS) will be used to assess difficulties in emotional regulation. The total scale shows an internal consistency reliability of 0.89, with subscales ranging from 0.79 to 0.88. The DERS includes six factors: awareness, clarity, goals, impulse, nonacceptance, and strategies, demonstrating good structural validity (Wang et al., 2007)

Four items from the catastrophizing subscale of the Cognitive Emotion Regulation Questionnaire (CERQ) will be used to assess individuals' tendencies toward catastrophic thinking about negative events, minimizing response burden (Li \& Li, 2019). The CERQ is a widely used self-report measure with good factorial validity and internal consistency (Cronbach's α = 0.75-0.87), and catastrophizing has been found to correlate closely with depression and anxiety symptoms (Garnefski \& Kraaij, 2007).

A self-developed Adult Alexithymia Scale will be used, comprising three dimensions: emotional restraint, difficulty identifying emotions, and emotional meaninglessness. Preliminary results suggest good reliability and validity, with psychometric research currently under publication.

A self-developed Adult Irritability Scale will be employed, which includes four dimensions: impulsive or destructive behavior toward objects, interpersonal aggression, negative self-perception, and aggressive impulses or actions. Studies indicate good reliability and validity, and supporting research is currently under review for publication.

The Family Attitude Scale (FAS) will be used to assess levels of expressed emotion (EE) within families, particularly expressions of anger, hostility, and criticism. The FAS is a 30-item measure that can be completed by any informant to provide an effective assessment of family climate. Findings show that the FAS has high internal consistency, good inter-rater reliability in assessing anger-related behaviors, and strong predictive validity (Kavanagh et al., 1997).

The Caregiver Strain Questionnaire (CSQ) will be used to assess stress experienced by family caregivers of children and adolescents with emotional and behavioral disorders. The scale contains two dimensions: subjective strain and objective strain. Studies have demonstrated that the CSQ possesses good reliability and validity (Brannan et al., 1997).

An adapted version of the Intervention Usability Scale (IUS) (Aaron R. Lyon et al., 2021) will be used to assess caregivers' evaluations of the usability of parent-child interaction methods. Usability is defined as the extent to which specific users can achieve goals effectively, efficiently, and satisfactorily within a given context. The IUS total score assesses overall usability of the intervention.

To further explore the mechanisms and potential biological underpinnings of the intervention, laboratory assessments and peripheral venous blood collection will be conducted at baseline and at the end of the intervention (Week 2). Laboratory tests (e.g., blood count and biochemical indicators) will assess general physiological conditions before and after treatment. Peripheral blood samples will be used for genetic analysis to identify potential biomarkers associated with suicide risk and intervention response.

The Sheehan Disability Scale (SDS), developed by Sheehan (1983), is a brief self-report instrument designed to assess functional impairment associated with mental disorders, particularly depression and anxiety. The scale measures the extent to which symptoms disrupt an individual's daily functioning across three key domains: work/school performance, social life/leisure activities, and family life/home responsibilities. Each domain is rated on a 0-10 visual analog scale, where 0 indicates "no impairment" and 10 indicates "extreme impairment." The total score, obtained by summing the three items (range: 0-30), reflects the overall level of disability, with higher scores denoting greater functional impairment.

The SDS is valued for its brevity, ease of administration, and sensitivity to treatment effects. It provides a quick yet robust estimate of functional outcomes complementary to symptom severity scales such as the PHQ-9 or HAM-D.

The CGI-E evaluates therapeutic efficacy relative to side effects using an NIMH-defined matrix. Higher values indicate greater net clinical benefit.

After completing the intervention, participants will complete the Client Satisfaction Questionnaire (CSQ), an 8-item self-report measure designed to assess overall satisfaction with the quality, effectiveness, and experience of treatment services. Each item is rated on a 4-point Likert scale, with higher scores indicating greater satisfaction. The questionnaire also includes an open-ended section allowing participants to provide qualitative feedback regarding their treatment experience. Research has demonstrated that the CSQ has good internal consistency and shows strong convergent validity with other satisfaction measures (Attkisson \& Greenfield, 2004).

At the end of the intervention, participants will complete the Working Alliance Inventory (WAI), a 12-item questionnaire designed to evaluate the therapeutic relationship between the participant and the counselor. Higher total scores indicate a stronger and more positive therapeutic alliance (Gaston, 1991).

After the intervention, therapists will complete an adapted version of the Working Alliance Inventory (WAI), consisting of 12 items designed to assess the therapist's perception of the therapeutic relationship with the client. Higher scores indicate a stronger and more effective therapeutic alliance (Gaston, 1991).

The Clinical Global Impression (CGI) scale, developed by the U.S. National Institute of Mental Health (NIMH) in 1976, is a clinician-rated tool that provides a global assessment of a patient's illness severity, improvement, and therapeutic response. The CGI-I assesses overall change from baseline on a 7-point scale (1 = very much improved, 7 = very much worse).