Thinking about suicide in this way, risks for ideation as a separate construct from risk for attempt gave rise to modern theories of suicide ideation. The first to clearly be structured this way was put forth by a psychologist at Florida State University, Thomas Joiner. In 2005, Joiner published the interpersonal psychological theory of suicide, which posited that in order for an individual to die by suicide, they must have both the desire for suicide and the ability to act on those thoughts and approach something as fearsome and potentially painful as causing their own death. The theory suggests that there are two internal states that when strong enough and persistent enough, lead to the suicidal desire peace. These are perceived burdensomeness and thwarted belongingness. Let's break each of these down briefly. A sense of perceived burdensomeness means that the individual thinks they're dragging down their friends, family, or community. Importantly, this is their perception. If you ask the friends and family of this suicidal individual, they would generally, strenuously deny that this is the case. But in the mind of the suicidal individual, they feel like their death is worth more than their life. The second condition the interpersonal theory suggests is needed for suicidal desire to emerge is the feeling of low or thwarted belongingness. This is the feeling that one is alienated from others. Again, friends, family, or community. This came from an overwhelming existing evidence that finds that social isolation is strongly related to suicide ideation. This has been noted across different populations, including adolescents, college students, military members, the elderly and psychiatric in-patients among others. Well, the combination of strong and persistent perceived burdensomeness and low belongingness is theorized to lead to suicidal desire or suicidal thoughts. Those are not thought to be important to the transition to suicidal actions without an additional element, something called acquired capability for lethal self-injury. Joiner posited that an individual had to have acquired the ability to act against the natural instinct for self-preservation and instead move towards the fear and pain that's involved in lethal actions. The capability could be acquired via life experiences. As more work on the theory came out, Joiner also noted that individuals come into the world with different levels of risk-taking and pain tolerance so that it might take less life experience for some individuals to be able to act on their suicidal desire than others. It's the combination of low belongingness, perceived burdensomeness, and acquired capability that result in the conditions when a potentially lethal suicide attempt can take place. Importantly, suicidal desire and suicide capability are orthogonal constructs. This means that they operate independently of each other. An individual may have never had a suicidal thought in his life and still have a strong suicide capability. You might imagine a daredevil young man who likes to skydive, who's trained as a firefighter. This individual came into the world with a high tolerance for risk-taking, engaged in a lot of recreational activities that reinforce that and then even trained in a career where he practiced moving towards danger, running into a burning building, and tolerating physical discomfort, overriding his natural instincts to avoid these situations. Now, if this individual never has a suicidal thought or desire, then his risk remains low. However, if he does have suicidal desire, his risk of attempting in a serious way is quite high given the fact that this capability is so high. Over the past 15 years, many tests of the interpersonal theory have been carried out, finding modest support for the theory. However, the interpersonal theory has also laid the groundwork for the next generation of what we call ideation to action theories. These include theories like the integrated motivational volitional theory, the fluid vulnerability model of suicide, the three-step theory and others. I'll focus next on the three-step theory. This is my area of expertise, but would offer the reminder that all theories are tools for reminding, for refining and communicating our understanding of a phenomenon. They're not set in stone, and they are simply waiting around for the next round of evidence in the next round of revision. The three-step theory was developed by my mentor David Shklovsky and myself and first published in 2015. The 3ST expands on the interpersonal theory in a couple of ways. First, it capitalizes on the evidence that we saw earlier that there are many risk factors for suicidality overall. Meta-analyses, a type of research that takes existing studies about the same construct and combines them to get a more precise estimate of the relationship among variables, finds that most variables on that long list of risk factors we saw, confer some risk for suicidal thoughts. But very few of them tell us anything about who's at risk of acting on those thoughts. Put another way, things like major depression, hopelessness or bullying, make it more likely that someone will have suicidal thoughts. But once we look just at the group was suicidal thoughts, none of these things gives us additional information about who of those individuals is that risk of acting on those thoughts. The first step of the three-step theory seeks to explain how all of these diverse variables can confer risk for suicidal thoughts or desire. It posits that the first step towards ideation begins with pain. If someone's experience of living is characterized by being in pain, this can understandably decrease their desire to live. Here we're usually thinking of unbearable emotional pain, but this likely encompasses physical pain as well. In contrast to other theories, like the interpersonal theory that highlight specific types of pain as being important, like being a burden or feeling excluded, the 3ST is agnostic to the source of the pain. All different sources of pain can diminish the desire to live. However, pain alone is not enough to cause suicidal ideation, hopelessness is also required. For example, think of a tax accountant in April, right before taxes re due. She may be experiencing a lot of stress, long hours, limited sleep, demands from her boss and clients, fears that she'll make an error, etc. However, if she has hope that this pain will abate, that she just needs to make it to May when her busy season at work is done, and some of these stresses will lift, she's unlikely to feel suicidal. Similarly, if someone's life feels hopeless and stuck, but it's not very painful, we wouldn't expect suicidal desire to develop. You might imagine someone who feels blah or uninspired by their life, but for whom it's fine and not actively painful or aversive on a day-to-day basis. They may not see a high likelihood that things will improve or change, but if the day-to-day is bearable then suicide ideation is unlikely. On the other hand, if someone's life includes unbearable pain, and he or she feels hopeless that the pain will improve, he will consider ending his own life. In this case, his life has become aversive, and he'll look for a way to escape it. In short, the combination of pain and hopelessness is what leads to suicide ideation. In fact, when we look at some data, this is what we see. People who are low on pain and hopelessness, not surprisingly, don't have much suicide ideation. More interestingly, people who are high on only one of those two constructs, either emotional pain or hopelessness, also seem to have relatively little suicide ideation. In contrast, it's the people who are high on both pain and hopelessness who report [inaudible] suicide ideation. The first step to suicide ideation is this combination of unbearable pain and hopelessness. The second step towards suicidal behavior occurs when pain exceeds connectedness. We use the term connectedness here in its broadest sense. Connectedness can mean connection to other people, as well as to an interest, a role, a project or any sense of purpose or meaning that keeps one invested in living. Think about it as the things that keep you tethered to life, even when life is very unpleasant. You might imagine a coach who's team is doing poorly, who's having problems in his marriage, who's depressed and hopeless, however, if his sense of connection to the team, and his sense of purpose and supporting his team outweighs that pain, then his ideation will worsen. On the other hand, if that connection to other people into that role as coach diminishes, the severity of his ideation is likely to increase. Among those with suicide ideation, if you're pain outweighs your sense of connection, your ideation is likely to worsen. The final step in the 3ST describes the progression from active suicide ideation to a suicide attempt. Here are the 3ST first draws on joiners existing theory of acquired capability that I described earlier. Individuals can acquire capability by way of repeated exposure to painful and provocative events that wear away at their barriers to harming themselves. The 3ST suggests that there are two other contributors to suicide capability in addition. First are dispositional contributors. These refer to contributors to capability that we're born with. Again, for example, some individuals are born with higher or lower pain sensitivity. We come into the world with different levels of risk aversion. You can picture one kid that eagerly jumps on a bike without training wheels and takes off, while another is hesitant to even try a tricycle. The second edition is the idea of practical contributors. Practical variables are concrete factors that make a suicide attempt easier. There are many kinds of practical factors. For example, someone who plans to end their life with a firearm and who has both knowledge of and access to a firearm, has much higher practical capability than someone with the same plan who doesn't have that access or comfort. Similarly, a pharmacist who has a lot of knowledge about the lethality and pain caused by different medications as well as easy access to them at the pharmacy, has a much higher level of capability than the average individual working around a drugstore. Higher acquired dispositional and practical capability are theorized to increase the risk that a suicidal individual act on their suicidal thoughts. Without capability, suicidal desire will not transition to a suicide attempt. One of the most valuable things to me about having a comprehensive theory, is that it offers up points of possible intervention. Where in this progression, can we break the chain and reduce the chances of a lethal suicide attempt? At least according to the 3ST, to influence suicide risk, we can lessen pain, increase hope, enhance connection, or reduce capability. As we'll see you in our next module on prevention and intervention, many of the evidence supported treatments for suicidality capitalize on one or more of these targets. Before we get there though, I think it's important to stop and think about the challenges of suicide research. How we conduct research with individuals experiencing suicidal thoughts and behaviors, and the ethical considerations involved. That work is what built the evidence-based we've been discussing, and allows us to test the interventions we will discuss. I think it's critical to stop and pay it some mind.
