Why people experience suicidal thoughts and attempt suicide and the psychology of combat sports: The Three-Step Theory of Suicide with Dr. David Klonsky, University of British Columbia (UBC) Professor in Clinical Psychology

In this conversation, Dr. David Klonsky dives deep into the Three-Step Theory of Suicide, explaining why some people consider suicide and some attempt suicide.

We begin the conversation with Dr. Klonsky talking about his side interest in combat sports and the psychology behind it. He shares his experience in martial arts and how it has influenced his understanding of the mental and emotional aspects of fighting. Dr. Klonsky also talks about his work as a consultant and analyst for combat sports, including his appearances on the Fight Network. He explains the importance of emotional readiness in combat sports and the role of approach-oriented emotions like excitement and anger. Dr. Klonsky emphasizes the need to overcome fear and interpret it as a natural response rather than a sign of unreadiness.

The main theme of the conversation is the study of suicide. The three-step theory is discussed, which includes the conditions under which people feel suicidal, the intensity of suicidal desire, and the capability to attempt suicide. Pain and hopelessness are identified as key factors in feeling suicidal, and the aversiveness of life is explored as a driving force behind suicidal ideation. The importance of understanding the distinction between suicidal ideation and suicide attempts is emphasized. The conversation explores the necessary conditions for suicidal desire, which include overwhelming pain, hopelessness, low connectedness, and capability. Pain and hopelessness are the primary motivators for suicidal desire, while connectedness acts as a pull towards life. Capability refers to the ability to overcome the barriers to suicide, which can be acquired through experience or dispositional factors. Mental illness, such as depression and post-traumatic stress disorder, can contribute to pain, hopelessness, and capability, increasing the risk of suicide. Understanding these factors can empower clinicians to intervene effectively and prevent suicide.

Special Guest:
E. David Klonsky

The following paper was referenced in the show:
The three-step theory of suicide: Description, evidence, and some useful points of clarification

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Transcript

Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a Professor of Counseling Psychology at the University of British Columbia. Welcome to episode number five of Psychotherapy & Applied Psychology. Here we dive deep with the world's leading researchers to uncover practical insights, pull back the curtain, and hopefully have some fun along the way.
Before we begin, I wanna thank everyone who's reached out to let me know that they've shared the show. Your support means everything. If you haven't had a chance to share yet, please consider sharing the show with just one person.
I can't communicate how much I appreciate it. On today's show, I am so excited to have this conversation with my excellent guest, who's a leader in the area of suicide. In our conversation about suicide, we discuss non-suicidal self-injury, ideation to action frameworks, pain, hopelessness and connectedness, capability for suicide, the association between mental illness and suicide, and clinical considerations.
In this conversation, we discuss but don't define ecological momentary assessment, which is a research method for studying people's day-to-day in-the-moment experiences. Suicide safety plans, which is a personalized plan designed to help someone who's experiencing thoughts of suicide to stay safe. Dissociation, which is when a person feels disconnected from their thoughts, feelings or identity, it's often used as a way to cope with intense stress or trauma.
And we also talk about Thomas Joyner, who's a very well-known suicide researcher. If you want to jump right to the meat of the conversation, just scroll to 15 minutes into the episode. But we begin the episode with my guest telling me about his fascinating side interest in the psychology of combat sports.
Without further ado, I'm thrilled to have one of the world's foremost experts in suicide, a professor in the University of British Columbia's Clinical Psychology Program, Dr. David Klonsky.
Yeah, I mean, I have done martial arts of various kinds for a long time, karate for a long time. Don't know if that was the best decision to invest my time in. I've been doing mainly jiu-jitsu and grappling arts for the last, I don't know, 10 years or so.
And yeah, I really enjoy combat sports. I mean, I've always enjoyed sports in general. I just love the idea that there's a task that you can commit yourself to that requires preparation and learning both physically and mentally.
I love that in the end, it's the strategies that sort of allow you to succeed. And I especially love when whether it's a team or an individual, because they're implementing strategies and game plans well, they can sort of beat the stronger, faster, more explosive person or team. I've just loved that since I was a kid.
And for me, there's something about combat sports, it's like the ultimate version of that. It's high stakes, you're in fight or flight, and yet you have to focus, you have to be strategic. If you're going to have success against someone who's, let's say, bigger, stronger, faster.
So I just really enjoy that. I've enjoyed that for a long time. And because I'm also a psychology professor, I've gotten more and more into psychology of combat sports, how can basic psychological principles of behavior, emotion, learning, be applied to help combat sports athletes of various kinds?
I've done some consultation. I've done some analysis here or there. I've gotten to be on the sports network and on the Fight Network here or there.
And yeah, I really enjoy it.
So can you give me an example of what that looks like, like one of the things that you've, Diven, Dovin, that you've gotten into? You can sort of, I'm curious.
Yeah, I always struggle with dove dived. I don't know what the answer is. Yeah, I can try.
There's so many different facets because there's my own training. There's when I've worked with individuals, there's sort of broad level analysis of professional mixed martial arts. So they're all sort of have different stories.
But I guess about 10 years ago, I connected with Robin Black, who's a Canadian combat sports analyst. And he at the time was working for the Fight Network. He since moved on to other things because he did a small segment on a psychological aspect of combat sports.
We connected and he ended up inviting me onto the show that was based out of Toronto. So next time I was in Toronto, I just went on and did about a 10 minute segment on the Fight Network, talking about psychology of combat sports. What are the psychological pieces of fighting?
And yeah, John Robin Black and John Ramdean, who are two long time analysts and me, and it was a big thrill. And yeah, just kind of introduced to the idea of what it means to be emotionally ready to fight, what are sort of the emotions that optimally support effective fight performance and those that get in the way. Talked a little bit about psychology of learning and preparation.
So can I just stop you real fast? Because I want like, so what are those emotions?
Yeah, emotional readiness. That's usually the part that people think of first. Like what makes you mentally tough or mentally ready?
They kind of treats the psychology of combat sports as a one dimensional thing. And of course, it's not. So I usually start there because people will think of like mentally tough meaning like you're not afraid, you're fully confident, you don't like wilt in the face of adversity.
Now, I have a lot of specific thoughts on the kinds of emotions that are most helpful. I think that versions of excited, most support approach related behavior, whereas fear is very much an avoidance emotion. That's why fear makes it so hard to perform well athletically or fighting is because to do any of these things, you need to approach and engage with your opponent in some way.
And fear is very much like, I need to get away from this tiger as fast as possible. So fear is in some ways the opposite. And even like sadness is also an opposite, although that's not one people often struggle with as much.
Sad is very much a resignation, withdrawal kind of emotion. So you want the approach related emotion. So excited works well.
Anger is reasonable because anger also supports approach and overcoming. Anger has some downsides and you can't necessarily be as thoughtful. So in general, the approach oriented emotions work better.
If you can be mainly excited or that's optimal for like a flow state. If you can't, if you have to choose anger, it's better than fear. But a big part of it is, you know, we're human, so we have feelings about our feelings.
And so feeling afraid and anxious is natural. And one of the biggest first steps for a lot of combat sports athletes is when you feel fear is not then interpreting it as meaning that you're not ready. Because that really shuts you down from sort of these optimal states.
And so 90 some percent of combat sports athletes, even at the highest, highest levels, even the best of all time, report extreme high levels of fear and anxiety among the other feelings they're having as they approach a fight. And so one of the first steps is just letting them, helping them accept that that just means that they're fighting. It's just normal.
It doesn't mean they're not ready. And then at least they can concentrate on the parts that they can control. They don't have to sort of have this meta worry that if they're afraid, it means they're not ready.
So that's usually the place where I start with a lot of athletes.
So there are particular ways that you found that helps them to accept, to accept that and perhaps interpret that fear in a way different from I'm not ready.
Yeah, definitely. I mean, the first is just the education, just the knowledge. And you can give examples of like, you know, George St. Pierre, GSPs, arguably the best MMA athlete of all time.
He reports having extreme fear from the start of his career to the end of his career before every fight. So even just the education that that is true, the normalization is a first step. Now, if it's a real problem, sometimes you can act.
I've sort of created drills for them when they're practicing leading up to a fight, when they're training leading up to a fight where I'll tell them, you know, just oversimplify for the moment. Think about the fear and all those fears you have and then execute the combination that you're working on in training. So it just gives them practice of instead of pairing fear with like doubt and paralysis, it's like pairing fear with action.
So it's like, all right, think about the fear and execute your combination. Think about your fear, execute your take down. Just so it's sort of creates a new thought action or new emotion action chain.
That's just an example of what can be done. There's all sorts of other things with optimal morousal, which athletes can sometimes have too high or too low before a fight. So we'll sort of talk about where do they want theirs to be for optimal performance and then how to get there for optimal performance.
I once had an athlete do the opposite, where before their biggest fight of their career, they kept themselves super relaxed the whole day. This is before I was working with them. And then when the fight began, they lost very quickly.
And their description to me was they felt like they weren't ready to fight. They couldn't shift from this relaxed state to a fight state. So there it was just basic education on optimal morousal.
And we figured out where he wants to be before fighting. And we just came up with some strategies to make sure he was at that point before subsequent fights.
Yeah, I think about that sometimes with sports where, particularly at the professional level, when you have a sport where your participation is at night, that you have to go through the entire day. And oftentimes for athletes, their training regimen starts early in the morning. So they're, you know, they wake up at five or six or whatever it is.
And then their game or their match or their fight is at eight, nine, ten o'clock. That, and for many athletes, it changes, right? Sometimes it's at one and sometimes it's at eight or whatever it happens to be.
And how they must have plans for how to go into that. And then thinking about, and they're in a hotel room, whatever it happens to be, how they have to plan for that, for that event, so they can optimally perform when the event happens.
Yeah, I think at the highest levels, they're thinking about these things. You know, you're bringing up a lot of things that are suddenly novel, that will tax the brain and the body in various ways. And there's a lot of things you can do in advance to make them less novel.
I've heard of fighters at very high levels leading up to the fight. They will just simulate the crowd noise. They will simulate the walkdowns to the cage.
Just so when they do it for real, it's not as novel. Novel things really get our brain's attention, which then means you have less resources for what you're supposed to focus on. It also means you're using more adrenaline, because novelty spikes adrenaline.
So there's all sorts of ways, even beyond the issue you bring up of routines being disrupted, where novelty in a high-stakes environment just drains us. And so there's ways you can just do things in advance to make those things less novel, more expected. And yeah, fight camps can absolutely plan for that, take advantage of that knowledge.
So getting back to what you said about being on the Fight Network, what was that like for you? And I guess when you first went into that television studio, and we've all seen where they sort of show the other side, from the other side of the desk, and there's a million lights and teleprompters and, you know, the fourth wall, you're able to see all of these people with these cameras. What was that experience like for you?
The shortest answer is it was terrifying the first time I did it. I mean, I had been on television a couple other times before. I'd done some new segment for CTV one time where I went to their studios.
But yeah, it's scary. It's different. And you're trying to sort of figure out the culture really quickly.
Now, what was really nice about the Fight Network is I met Robin and John, the two hosts of the show called Five Rounds, the evening before, and we had beers together. So that sort of helped make it a little, you know, feel a little bit better. And that they also are really good at their jobs.
They know, you know, they're used to people who are maybe guest experts, but who aren't seasoned TV professionals. So they just, they know what they're doing. That said, I was still very afraid and uncertain.
I knew the segment was supposed to be pretty short. Fortunately, it went really well. And on the fly, this is another piece of evidence that they're professionals, on the fly, they were getting their earpiece, I guess, from the producers, information to keep it going, even though it was supposed to be, you know, three or four minutes, they ended up making it like a 12 or 14 minute segment because the producer thought it was going well.
And they didn't, I mean, they didn't miss a beat. They just alternated questions. It was a lot of fun.
And what was interesting is they had me on another time, that's roughly a year later, and I felt like less nervous that time and more prepared. But I don't think I did as well based on the comments on YouTube. So I think I overthought it or there was something good about being maximally a deer in headlights where I was just my natural self.
So what was, in doing this podcast, it goes up on YouTube as well. And to this point, nobody's left any YouTube comments. And I'm sort of like both looking forward to and dreading when that starts happening.
What was that like for you? First, the decision to look at the comments on YouTube and then reading the YouTube comments.
I mean, I really cared what people thought. Fortunately, they were mostly positive, which felt great. And they kind of got what I was trying to get across.
They kind of got that I was a professor who just genuinely loves MMA and is applying the psychological principles. And most of the comments were like, cool professor. You know, like things that felt really good.
You know, there's some comments that were negative, but they were mainly just misunderstandings or like things that didn't really matter. But you know, I have a very quantitative mind. And at the time, YouTube is still allowing like the number of dislikes to appear, you know, when you have the thumbs up and the thumbs down.
So I was really paying attention to the ratio. What's the ratio of likes to dislikes? Because most videos on it for Fight Network, you know, at that time were mostly positive.
So I was looking at the ratios and I noticed the ratio wasn't as good the second time.
I'm sort of, in talking about this, I sort of think that me being completely naive to this whole world, we could easily, I sort of feel like we could record two episodes right now and we could spend an hour on this and then an hour jumping. But yeah, it's fascinating, it's fascinating. So let's sort of jump a little bit in topic.
And actually before we get into it, one of the things I wanted to try to do, because I'm talking to these folks who by any metric have been exceptionally successful in their careers. In your case that the work that you've done, not only have you been very productive and produced quite a lot of it, but also it has had an impact. And there's obviously our traditional metrics for measuring the impact of the work that we do.
But I can say being in the suicide world that I talk to people pretty regularly who are either researchers, students, practitioners, who your work has had an impact on them and really has impacted how they think about things. So, but that being said, that wasn't always the case, right? You started at a certain point in your career and you had, you know, just like all of us, you had a lot to learn.
So my question is, when you think about an earliest point in your career, what was a time or an experience that you can remember where you said to yourself, oh, I don't know if I can do this. So that could be on the research side or on the clinical side. And then I'm going to ask you the inverse as well, which is going to be, what was one of the times earliest in your career when you said, you know, you accomplished something, you got certain feedback, whatever it happened to be, where you said, oh, I think I might be able to do this?
I mean, surprisingly, I have relatively specific answers to these questions.
I'm not surprised at all.
I mean, I know that when I was in grad school, but this is going to be followed up by something different. When I arrived in grad school, I felt I am meant for this. This is just where I feel at home.
And I say that as someone who spent most of his life not feeling at home, whether it was socially or academically, I didn't know exactly what I was good at. And something about this psychology research finally felt like this place to my strengths, and it hides maximally my weaknesses. This is perfect.
In grad school, I also figured out quickly that I enjoyed, enjoyed is not quite the right word, I appreciated clinical work. It mattered a lot to me, but I found it so draining, so overwhelming. I felt such an obligation to do a good job for the client that after one session, I would feel like I am done for the day.
I was drained. Whereas research, I always just found exciting. And if I was having beers on a Friday evening, I'd want to talk about it.
So it just, all signs were pointing, this is what I meant for it. Now that said, I remember when I took my first faculty position, and part of me felt like if I had infinite time, I think I could be good at this. But the seven-year tenure clock, I don't know that I can do this.
So I remember my first and second year. It was just awful. I think I just spent the entire year manic and anxious and scared and not knowing if I could make it.
And it was around my third year when I started having enough publication and grant success. Then I started to think like, okay, I think I'm going to make it.
Yeah, I think that that's... I think there's value in, you know, for everybody, myself included, when I'm talking to people who are, again, by any metric, extremely, extremely successful disorder, that take a moment to be like, all right, they weren't always like this, and that it was hard for them as well. So we're going to talk mostly about your research on suicide today.
So how did you get into studying suicide?
I mean, the truth is, is a little bit accidentally. The interest that was more organic was non-suicidal self-injury. And I remember the first time I learned about NSSI, non-suicidal self-injury in undergraduate, just finding it inherently interesting, because it just sort of goes against, if you don't have experience with it, it goes against your intuitive sense of how people work.
We want to avoid pain. So why do some people on some occasions self-inflict pain and injury? And it registered, but I didn't really do anything with it.
And then in grad school, one of my early clinical practica, I encountered someone with a schizophrenia diagnosis in a hospital, but who also had a self-injury history. And at the time, DSM-IV said self-injury is borderline personality disorder. So I asked my clinical supervisor, how often does someone without borderline personality disorder have self-injury?
And they said, it's a good question. I don't know. And then I said, well, does everyone who self-injures have a diagnosis?
Are there some people who are just kind of reasonably adaptive, functioning well, who also self-injure? And he said, I don't know. And I just found the behavior inherently interesting.
I think I was drawn to anything in human nature that seemed like it didn't make sense because it should make sense. I was struck by how little people seem to know about it, even people who are experts. I was struck by the obvious disjoint between the official classification of self-injuring, the diagnostic manual and just how it manifested.
That was the intellectual side of it. On the more emotional side of it, most people, I'm guessing, have various kinds of distress that are hard for them. Depression is hard for a lot of people, anxiety is hard for a lot of people.
For me, it was mainly anxiety and a sense of socially feeling like I knew the social rules. That was a real struggle. Just my interest in psychology in general was just wanting to understand us better, understand people better, understand the human condition better.
A lot of times when you're studying things like personality disorder, which is where I started out in grad school, there's a sense of you don't know for sure if you're studying something real. It's not concrete. You're sort of asking a bunch of questions that are mapping on theoretically to a latent construct, but our definitions of these constructs change.
Even our names for them change. But self-injury is just undoubtedly real. It's an actual behavior.
There's no denying that it's a real thing. For a lot of people, it comes with distress. And yet, it's not understood.
And so there's a lot of people who are experiencing distress in some way connected to this behavior, and yet those people don't have understanding. And I think for me, on an emotional level, that really bothers me. That combination of people being in distress, but they're not understood.
I really don't like that. I hate feeling that way about myself. If I'm in distress, but people can't understand it, it's one of the worst feelings, and I just don't like that that existed.
So this constellation of stuff got me very interested in self-injury, became my primary area of focus in graduate school, even though it was not my advisor's focus. But then, a very long explanation to get to suicide, you can't study.
Before we go there, just real fast, what is non-suicidal self-injury, and how do we differentiate it from suicidal self-injury?
Non-suicidal self-injury, probably the most prototypical behavior people hear about is cutting the skin, but you can take other forms, burning, hitting, scratching, others. And it's, at least conceptually, it's non-suicidal because the intent is not to end one's life. The intent is something different.
Turns out, at least in most cases, the intent is some form of, you know, people are experiencing sort of high arousal, negative emotion, and something about engaging in self-injury temporarily alleviates these emotions, or at least the emotional arousal. And that seems to be the, you know, the briefest version of self-injury I can give, even though, of course, there's a lot of nuance and variation. It's not suicidal, because these people are not trying to die.
They're trying to feel better, but they're very much also trying, they're trying to live while feeling better, which is different than wanting to end your life. Now, that said, to me, it's obvious that these are different behaviors with different intents, but not everyone agrees with that, and certainly going back 20 years ago, not everyone agreed with that. People love to see self-injury and suicide as on the same spectrum, whatever that means.
I think we should always be suspicious when people say something's on a spectrum. I really think it's shorthand for we don't really understand what's happening here. And so at the time, it was sort of novel to see, it was a little bit novel to see NSSI, non-suicidal self-injury as distinct from suicide attempts, which also meant at the time, I was running into tons of people who their first question when I say I'm studying self-injury is, what's the difference between that and suicide attempts?
Or what's the relationship between that and suicide attempts? And suicide attempts have all the same features that make non-suicidal self-injury compelling to me. There's clear suffering.
It really matters. They're not well understood. It conflicts with our sort of layperson's intuition of how people should operate.
And these are people who deserve and need understanding. And these behaviors are undeniably real and concrete. All of that together just, I guess, made them a fit for me to want to put my energy into understanding them better.
So I interrupted when you were really going down the road of how you got into studying suicide.
I mean, the answer is, I was studying on suicidal self-injury, I guess this is mid-2000s, but over and over again, people then want to know what its relationship is to suicide. And so then I started wanting to understand that too. Now, I know a lot of times for these kinds of questions, people will have personal experiences to share.
For this particular one, I don't have that. But I have something different, which is that I also was starting to... I took my first faculty position in 2009.
I wasn't ready for it. It was the ideal position for me, but I wasn't ready for it. I didn't do a postdoc, and it was even worse because I was studying self-injury at the time, which was not what my advisor's focus was in grad school.
So I didn't have a lot of sort of mentorship on that topic. And I needed grant funding, and American Foundation for Suicide Prevention offered some small grants, and it exists because they're trying to pull young researchers to study suicide, and that's what happened in my case. I had access to a large data set where I could look at impulsivity and suicide attempts.
I got a small grant to do it. It was my very first independent grant, other than a grad school one, and I remember I cried a little bit when I saw that I got it. And it's what made me do my first study on suicide, and the results were not what I expected, and that ended up being a rabbit hole that still hasn't ended.
So when you say the results weren't what you expected?
Yeah, it was a data set where we had, it was, you know, like 2,000 military recruits, and we happened in that data set to have measures. The whole purpose of the data set was to look at the way, correspondence between how I describe my personality disorder features and how people who know me describe them. That was the purpose of this project.
But we happened to have measurement of histories of suicide attempts and also suicide ideation. And we had measures of a ton of personality disorder characteristics, not just the DSM ones, things like impulsivity. And so really, the purpose of the study was to show what everyone knew is true, that people who attempt suicide are more impulsive than people who consider suicide but don't attempt.
But that's not what happened in the data set. What happened in the data set is that people who attempt suicide scored the same on impulsivity as people who seriously consider suicide without attempting, which was confusing, not what I expected. Coincidentally, I had access to another large data set this time of adolescence where we had multiple measures of impulsivity with suicide attempt and ideation histories.
And the findings were slightly more nuanced, but basically the same thing happened. People who attempted suicide were just not higher in impulsivity compared to people who seriously considered suicide. Both of those groups were way higher than people who had never considered suicide or attempted.
But those two groups, who thinks about suicide without attempting and who actually attempts, were the same. And that conflicted with what most people thought. People saw impulsivity as the quintessential personality trait that determines who acts on these kinds of thoughts and who doesn't.
And so it was an unanticipated finding, but I was ready to embrace it, the data are the data. And that ended up raising a whole bunch of other questions, and I sort of never stopped trying to make progress on these.
So this leads perfectly into the next place I want to go, I think. But before we go there, I kind of want to put a bow on this. Is that still your understanding that impulsivity is not a strong distinguisher between folks who are having suicidal thoughts and folks who act on suicidal thoughts?
Yes. I think sometimes, I think when people use the word impulsivity vaguely or incorrectly, then there's versions where attempts are impulsive. But impulsive ends up just being a synonym for didn't see it coming.
It's not a mechanism. When people try to say something is impulsive, what they're really trying to say is something about the mechanism, the reason. And it doesn't work on that level.
If you're using impulsive just as sort of like a descriptive term of like we didn't see it coming or the person didn't see it coming, then yes, things can be impulsive. But that's not the explanation is different from that.
So to put it another way, that impulsivity isn't causal.
Yeah, yeah. From a descriptive perspective, we're all impulsive water drinkers. You know, how much time elapses from the time you have an urge to drink and how much time you like actually get a drink of water or something else.
Like most of the time we're talking minutes and sometimes seconds. Sometimes it's longer for the middle of this podcast and you're thirsty, you might wait an hour because you might want to wait till it's done. But even that by most measures of impulsive suicide attempts would mark you as an impulsive water drinker.
So, you know, like it's there's a lot of times where we have urges to do something, we act on them quickly and it's just normal. The explanation is not that you're impulsive water drinker, it's that you're acting on a particular sensation that came up at that time. And that's not that doesn't make you impulsive.
So, you know, scriptively, you'd be an impulsive water drinker, but mechanistically, impulsivity is the wrong term.
Got it. So what you were saying really does lead into, I think, and correct me if I'm wrong, into your work looking at an ideation to action framework. So this, actually, could you explain sort of generally before we get into your specific theory, could you explain what an ideation to action framework is?
Yeah, I'll do my best. It's simply that the recognition that what explains feeling suicidal versus what explains the subset of people and subset of times that ideation translates into actual attempts, action, those are separate processes with separate explanations and separate predictors. So if I want to explain why someone's feeling suicidal, that will be a different explanation than why that person one time, over the many times they felt suicidal, decided to act on that ideation.
We shouldn't just sandwich those together and treat them as a single phenomenon, that we need to have separate explanations for what leads people to feel suicidal, versus what leads people some of the time to act on suicidal ideation and make a potentially lethal suicide attempt. So that's the term, that perspective is what we're using the term ideation to action framework to reference.
So the, yeah, I sort of think about it as, and we'll get into it, thinking about like taking steps in a process to act on suicide, that you go from not having suicidal thoughts to then having suicidal thoughts or desire, to then, you know, wanting to act on them and then actually acting on them, sort of like these steps in a process rather than just an on-off switch.
Well, sometimes there are steps, but sometimes it's not. It could be very nonlinear. So for example, you take someone who's attempted, I don't know, let's say twice in their life, you know, they had, they felt suicidal.
At some point, they made an attempt, then they're still alive. I'm guessing time passes, maybe sometimes they feel suicidal, maybe sometimes they don't, but then they make another attempt. So it's, I mean, there's a way in which it's hard to conceive of an attempt without ideation.
So like, at least the first time there needs to be a temporal ordering. But to me, that's not the key feature of it. And it is, it's more about the times in which ideation occur and the times in which ideation progresses to an attempt.
It's just explaining those times, but those times can, you know, they're not just linear.
I have more questions, but I think the thing to do will be for us to dig into the three-step theory, which you developed, and then to integrate those questions into there. So do you want to start with what would make sense? Would it make sense to go step by step or would it make sense to give broad overview and then?
I don't know. I will say that since we're talking about the time issue, one of the most common misconceptions people have about the three-step theory, from my perspective, it's an unnecessary, it's an incorrect extrapolation, but they think that the three steps have to happen in a certain temporal order, even though embedded in every paper I write about it are examples that violate that expectation. For example, people can walk around with high capability for suicide without ever feeling suicidal.
So like step three conditions can be before step one, and like people read that and no one has questions about it. And yet a lot of times when they describe the theory, they're like, okay, so first step one happens, then step two, and then step three. It's like, no, it's actually not true.
They just, each step just describes the conditions under which something will occur. But those conditions can come in any version.
So I think let's do, if you wouldn't mind, give just a 30,000 foot overview and then we can dig into it.
All right, I will give a 30,000 foot overview with the qualification that this will force me to greatly oversimplify. So if anything sounds too simple, it probably is. And if we want to dive into that piece, I'll have a lot more things to say that will make it sound not simple.
The first step addresses the question under what circumstances do people feel suicidal? Do people have desire to die? And the answer is when two conditions are met.
People are experiencing overwhelming pain, usually psychological or emotional pain, but physical pain can count, in combination with hopelessness that things can get better. There's so much I can say about this. The nature of pain, why we're starting there, why that's a mechanistic statement and not a broad statement, all the ways that it's possible to have pain without hopelessness.
It's even possible to have hopelessness without pain. And in all those conditions, you will not feel suicidal according to the theory. You really need both to be present.
And so I'm feeling such a need to elaborate on so many pieces of this.
I think if you let's do this level for the three, and then we will dig in, because I already have several things I'm going to come up with each one.
I'll stay 30,000 and resist the urge to clarify all the pieces. So if you're experiencing overwhelming pain and hopelessness, you will feel suicidal. Most people, though, when they feel suicidal, it's not strong.
You know, when we look at ecological momentary assessment, diary studies of people who feel suicidal, we can sort of look at the ebb and flow. Most times when people feel suicidal, they describe it as modest and intensely not strong. The second step of the theory addresses under what conditions is suicidal desire strong or intense rather than modest.
And the theory states that suicidal desire is strong when pain exceeds or overwhelms connectedness. The idea here is whereas pain is the push from being alive, and that applies to the first thing we should talk about when we cycle back. Connectedness is what can make a very painful existence feel worth it.
But if your pain is dwarfing your connection to life, or in some cases when pain is so severe, it just takes away your ability to engage or appreciate connections you otherwise would have, then not only are you in intense pain and feeling hopeless that things will get better, but there's nothing that's making it worth it, and that's when suicidal desire is stronger. And then the final step says when does strong suicidal ideation progress to an actual potentially lethal suicide attempt? And it's an important question because most people who feel suicidal do not attempt.
Most instances of suicidal desire do not lead to an attempt, so under what conditions does strong ideation lead to an attempt? Step three says it's when the capability to attempt suicide is sufficient. Capability was a concept introduced by Thomas Joyner, who simply made the point that we are deeply wired to fear injury, fear pain and fear death.
These are barriers that are arguably evolutionarily wired into us, biologically wired into us, and they have to be overcome to attempt suicide. And so there's a lot he said, and we've sort of elaborated his initial conceptualization and described what it means to be capable of attempting suicide, capable of overcoming these sort of wired in fears. And so just to complete the bird's eye view, are you experiencing overwhelming pain and hopelessness?
If yes, you'll feel suicidal ideation. If not, you will not. Is your pain seeding or overwhelming your connectedness?
If not, your ideation will be modest or occasional. If it is, your ideation is strong. And finally, are you capable of acting on your suicidal ideation?
If not, then you'll be among the majority of ideators who do not attempt, or you'll be experiencing the majority of instances of ideation that do not lead to an attempt, even strong ideation. But if your capability is sufficient, then that's when the attempt will occur.
Great. Thank you. I think that will be helpful.
Then when we dig into it, people have a larger context in which to hold it all.
Hopefully. There's nice figures in the papers that I feel like make all of this easier to follow than a seven-minute bird's-eye view explanation.
Let's dig more into it. So pain. You said that pain can be psychological or sometimes physical.
So help us understand what you mean by pain.
Well, one of the hardest questions to address when you're dealing with why do, in some cases, people want to end their life or actually try is it doesn't make sense. We are obviously so wired to not want to die. It is built into our belief systems where we have stories of how death isn't really death.
We'll keep living. You'll keep living if you follow certain rules. We have seat belts and all sorts of fire codes.
I mean, we just wrap anti-death measures into all aspects of human life. And so clearly this is an instinct. So to explain suicide, you have to explain how is that instinct not taking priority in some instances.
And so my answer to that is something equally fundamental is that we are creatures of behavioral conditioning. We are deeply wired from birth to want to avoid situations that are aversive and painful. So even a young child touches a hot stove and burns their hand, they will take that hand away really fast and not touch that stove again.
You know, when you meet someone who you don't enjoy talking to, you really want to avoid that person. You do not want to hang out with them again. You will go to great lengths to do that.
So this is just, you know, we are very much behavioral creatures. If something is rewarded, paired with reward, we want to do more. If something is paired with punishment, we want to do less.
This is also fundamental. And so if someone's experience of being alive is that it is painful, it is miserable, it is aversive, that same instant kicks in that I don't want this anymore. So it's a deeply mechanistic place to begin.
But we can't ask, it doesn't make sense to ask, what's the specific kind of pain? Because it's similar to asking, what's the specific kind of negative experience that makes us not want to do something anymore? Well, I mean, they're infinite.
It could be physical pain. It could be that it makes us feel terrible. It could be that there's a noxious smell.
It could be that this person makes me feel bad about myself. It's infinite. All those things kick in that instinct, I don't want this anymore.
So same thing. If your life is just engaging with life feels aversive and miserable and painful, then the instinct kicks in that I don't want this anymore. Most of the time though, we will have hope that there's a way out.
With effort, with circumstance, with time, there's a way out of this. So when we're experiencing that thing, that pain, our focus is on how to get out of it. But if you're also hopeless that there's a way out, that's when you start to feel like maybe being alive isn't for me.
So, reconceptualization of pain, you sort of made me think in a way I haven't thought before that, I mean, I do typically think of pain as obviously a physical pain or even an emotional pain, right? Something where my experience is it hurts. But you're taking it a little more down to the studs by saying, I don't know if I'm right or not, that to think about it more that pain is the thing you experience that because we're so hardwired not to want to experience it, that pain is the thing that makes us say or that can lead us to say, I don't want to live anymore because I don't want to experience this pain.
I like the term aversiveness, but I was convinced that that had too many syllables.
Say more about that.
Well, anything that's aversive, we don't want to deal with it anymore. And it really is such a deep instinct, we just take it for granted. But we really walk around the world that way.
Things that are aversive, we really avoid. And so for some people, even being alive is aversive, and there could be so many possible reasons for that. It could be a depression that just will not alleviate, and it's severe.
It could be the overwhelming financial pressures that you don't know how to solve, makes you feel terrible about yourself, you feel like you're just hurting. There's so many ways to feel that life is aversive, but if you spend enough time feeling that life is just aversive, I don't want this. Now, again, in the beginning, you're going to be life's aversive, and you're going to be so focused on how do I solve this, because you still have hope.
So that's why the pain or the aversiveness by itself doesn't just lead to suicide. But when you get to the point where life is just aversive, and I don't have hope that there's a way out, that's when you start to feel like in your bones, like I don't want this anymore, and maybe being alive is not what I want. So aversiveness is a broad term.
I mean, I acknowledge that, but I also just think that's literally the way human experience works. There's a lot of things that will make experiences or life feel fundamentally aversive.
First of all, I understand why, I'm assuming your colleagues discourage you from using the term aversive and using the term pain. I understand that. And I also think you saying, changing your language from pain to aversive, it expanded my thinking.
As soon as you said that, I had a different framework for thinking, I mean, slightly different framework for thinking about it. Because aversive is, it's so, it feels more subjective, like, you know, that there'd be more between person variability, right, that some people find certain things more aversive than other people. And it just goes beyond having a, the manifestation being clearly like equivalent to some sort of a pain.
I don't know, it just, it broadened my thinking.
Yeah, I mean, aversive is what resonates with me. And, you know, I wish there was a perfect synonym for aversive that wasn't as obscure for people.
And I think that, so, I was thinking as you were talking about the hopelessness piece, that oftentimes when we experienced aversiveness, we have some sort of hope, we have a, this is going to end.
Right?
When we were at the front end of, before we started recording, you were telling me about how you had all these deadlines do, you know, you had all these deadlines last week that were consequential and important. So you were super stressed out. And then, you know, you met those deadlines, that's over.
Right? So you knew even when, you know, last Wednesday, when you're like thinking, how am I going to, you know, be a good parent while still finishing this grant application or this grading or whatever, you knew that it was temporal, that it was going to be short lived.
Right.
But when you don't see a light at the end of the tunnel, that's what takes that really aversive experience and cranks up the volume of it on it, or particularly cranks up the volume on the desire to get away from, to escape life because this is so aversive and I don't see a way out.
Yeah. But the thing you just said at the very end there, it's so aversive that that also matters. So the hopelessness matters, but also just like the extent of the aversiveness matters.
Like, you know, it's not literally like any tiny little thing, just, you know, that's aversive. That doesn't necessarily make life feel aversive. I might quite enjoy life, you know, even when I have deadlines, or I might have some mixed feelings, like there's some, you know, overall life is a six out of ten on life satisfaction, you know.
So it needs to, you know, there's a way in which the totality of life, at least in that moment, needs to feel aversive, like just painful, overwhelming, miserable. Different words resonate with different people. If someone else who said emotional misery was the word that they thought was the right word.
I think misery works in a lot of cases, but not for all cases, because I do think that physical pain and medical conditions can count. But different words resonate with different people, and I agree that pain is not the perfect one for me. It's aversiveness.
It sounds like that works for you. But yeah, it's like, is life fundamentally aversive and are you hopeless that this is gonna change? That's the combination that makes someone feel like maybe being alive is not for me.
So do you think about hopelessness as a... I know you think about it in terms of sort of, in a way there's sort of an interaction there, right? That high aversiveness and low hopelessness, I'm sorry, high aversiveness and high hopelessness is where you get into trouble or start to experience suicidal desire.
Do you think that that hopelessness contributes to the aversiveness? Does that make sense?
Yeah, definitely. Right, hopelessness doesn't feel good to feel hopeless. It's an aversive cognitive affect state in itself.
And also the other way works too. I mean, the longer you're in pain, the more you're going to start to feel hopeless that there's a way out. So, of course, these psychological factors can inform each other.
Really though, I'm just trying to specify the necessary conditions from my perspective that bring about suicidal desire. And according to those necessary conditions, pain and hopelessness don't have to have causal impacts on each other. But of course, they often will.
So, when we get to… So, that's what you're saying, the necessary conditions for suicidal desire. I believe you call it modest suicidal desire.
And then sort of…
Stop thinking suicidal desire. We don't know at this point what the suicidal desire is until we analyze the step two conditions.
So, when we get to step two, you talk about connectedness. Before we get into the nuance in terms of how much and that sort of thing, can you explain what connectedness is?
Yeah, I appreciate you asking because we do define connectedness more broadly than some other suicide theories. Connectedness can be to social kinds that we're used to thinking about, friends, family, loved ones, partners. But we also acknowledge it could be to a community, it could be to a sense of identity, it could be to a pet, it could be to a cause that you believe in.
Really, a connection to any sense of meaning or purpose counts from the theory's perspective. So we do have a broad definition of connectedness. We're actually exploring it empirically.
You just understand better how social forms of connection and meaning and purpose, to what extent are these one and the same or different. But for our purposes, we define connection broadly. And it matters because just as I described a moment ago, how when life's aversive, that's the push that I don't want this anymore.
Either I don't want it anymore because I'm going to create a better future or I don't want it anymore and I don't have hope to create a better future. I just, so I'm feeling stuck other than not about being alive. Connection is the pull to being alive.
Connection is what makes life worth living and gratifying and rewarding and meaningful. And so if, even if you have the step one conditions in place, if you also are able to engage with connections that are valuable to you, you'll still at times feel like, you know, like, gosh, like life is so miserable and it's not going to get better. And like sometimes I don't know if I want to be alive, but it's not going to go stronger than that because you are engaged with things that matter to you that make the pain worth it.
Versus, if you don't have those connections or sometimes when pain is so overwhelming, it's like you just end up feeling disconnected from your connections. You just can't engage with them. You can't appreciate it.
Then it's like life's subversive. I have no way out of this. There's nothing that makes it worth it.
You know, that's when that suicidal desire becomes stronger.
So connection gives me purpose, gives me meaning, gives me purpose. So if I have, I think about, if I have, for example, a dependent, that could be a pet, that could be a kid, a partner, a parent, a plant. Something that, or even something more nebulous, like a company or a place you volunteer at or whatever it is, something that says, there's something that gives me purpose, that I contribute to, that would, that's better off because I'm here.
Yeah, that matters to you. Yeah, that gives you a sense of meaning and purpose. Yeah, there's, I can't remember the author's name, but there's an author who died by suicide, I think a couple decades ago, I wish I could remember the specifics.
But his suicide note began by saying that football season's over. And, you know, I just think it was, you know, it was his way of saying like that, I was engaged with the football season, I cared about following it. And that was enough to sort of make life worth living.
But now that it's over, I don't really have anything that makes it worth living and I'm not particularly enjoying it, and I don't really see that changing. So I decided to end my life. So it could be a favorite TV show that you look forward to seeing, just something that you feel connected to that brings enjoyment, that pairs life with positive.
So sort of the combination of pain and hopelessness sort of subtracted from, this isn't literal, but kind of conceptually from...
What's interesting is that it's not that. Everyone goes there. It's not pain and hopelessness versus connectedness.
It's pain versus connectedness. And I need to figure out a way to sort of make this more intuitive or say it better or something, because everyone goes there. Pain is the push away from life.
Hopelessness is the direction that that push takes. Because if there's hope, the push is changing your circumstances. If it's hopeless, then the push is not being alive.
So hopelessness is the direction that the push takes. Pain is the push. Connection is the pull towards life.
Hopelessness is the direction that the push takes. It's just that when we're thinking about suicide, the connection piece doesn't matter if you don't meet step one conditions to begin with, just in terms of logically, not temporally, but logically. You know, if you're not in pain, even if your connections are low, you're just not feeling suicidal.
Because you don't have that push away from life to begin with. So you need the push away from life in the form of the pain or the aversiveness or the misery. And when it comes to suicide, you need the hopelessness if the direction of the push is towards not being alive.
Otherwise, the direction is towards a future where things are different.
I'm trying to think of a question to ask, but I want you to expand on that a little bit. I can't come up with a question right now.
Let's see. Well, I mean, if your life is painful, miserable, aversive, let's say you started your first year of grad school, and you're in a new place, you don't have friends, everything's stressful. But if you have every sense of, things will get better with time, I'll learn how it works, I'll meet new friends, then your aversiveness, your misery might be quite high, but you're not suicidal because you just have all these reasons to think that things can get better.
And so, in terms of, are you feeling suicidal? We don't even have to worry about the other conditions in terms of how you're feeling at this moment. We might want to worry about the other conditions if we're thinking about your suicide risk in general.
If you're someone who has high capability for various reasons, you know, they're at higher risk if you should develop suicidal desire. But in terms of the part of the theory we're focusing on now, that person might have very high aversiveness, very high pain, misery, but they're not feeling suicidal because they have the hope that things will get better. So the direction of the push, pain is pushing them to like, they really want to get to a place where things are better, which is not the same as, I don't know if being alive is the right choice for me.
That only comes when you have the hopelessness. So if you have the pain, high pain and hopelessness, and you're like, oh, this sucks, I don't really want to be alive, but you have high connection, then you have another piece that connection is like, yeah, but life actually has some things that really matter to me. These things are meaningful to me.
It makes the pain worth it. So it ends up being, if you get to the point where the step two conditions matter, then it's sort of the push of the pain versus the pull of the connectedness.
So how do you think about the relation between connectedness and pain, that if I'm feeling disconnected, that that in itself is painful?
Yeah, for some people that will be a cause of pain, even the primary cause of pain. For other people, it doesn't really matter that much. So again, the theory is just the necessary conditions.
But why people feel pain could be intimately tied to connections. I mean, for some people, it can happen fast. A significant relationship ends unexpectedly.
And I mean, that might be incredibly painful. You might have in that moment no ability to imagine what your future is going to be like, because your future was tied in your mind to this person. And now your main connection is gone.
So those conditions can come about very, very quickly. But for some people, that's not how it works. For some people, pain comes from other kinds of things.
It can come from a chronic illness that's just getting more and more painful. And that makes day-to-day life, like you're just always suffering. And every day is more suffering, so pain can come from other things too.
And maybe this person has a lot of connections, but over time, if you're just physical pain or agony even every day, you just can't appreciate those connections as much. And eventually, it's like life's subversive. I have no hope that this is going to get better, which might be accurate.
That might be the prognosis. And I just can't engage with these connections in a way that I'm just in pain. And so those also are ingredients that can sort of meet the conditions of step one and step two.
Okay, so step one, just to summarize before we jump on to step three. So step one, we have life is highly aversive, and I see no way of getting out of it. That's that hopelessness.
So it's highly aversive, and I don't see a light at the end of the tunnel. Additionally, I don't feel like my life has meaning or purpose. That's that idea of not feeling connected, right?
High pain, I'm sorry, let's use aversion, high aversiveness or pain, high hopelessness, low connectedness. So I don't have any reason to hold on. So I sort of think, so why am I...
So I have this pain, but I don't have a reason to sort of struggle through it.
It doesn't make nothing... Yeah, it's nothing that makes it worth it.
And then getting to step three. So step three being where folks will have, they go from that strong suicidal desire to actually an attempt, is that capabilities, and Joyner, I think, could say acquire capability or capability for suicide. So could you unpack that a little bit?
Yeah, Joyner introduced acquired, but all of us, including Joyner, have expanded capability far beyond acquired at this point. I don't know if Joyner ever formally did it, but you can see in what he writes how he is way beyond acquired, and he's at least said... I'm trying to remember what the format was.
I don't know if he's written it or just said it, but he said he really regrets calling it acquired. He should have just called it capability. So yeah, the ideas I explained earlier that suicide...
Attempting suicide is scary. We are wired biologically, arguably, evolutionarily to avoid and fear death, avoid and fear injury, avoid and fear pain. It's very hard to overcome.
Those are barriers to attempting suicide, and it is very hard to overcome those barriers. And so Joyner introduced the idea that when people can be more or less capable of overcoming those barriers and thus more or less capable of attempting suicide and ending their life. His initial conceptualization was about acquired capability, that you could sort of acquire this capability over time through experience with what he called painful and provocative events.
This is sort of a large, infinite universe of events that will give you experience or contact with death or injury or pain and help habituate to those things, sort of just make you more able to deal with them. What are examples of these painful, provocative events? I mean, it could be like a firefighter who is always rushing towards potential death and even being around people who have died or have had injuries, and you just sort of are less impacted by those things over time.
You have more experience sort of persisting through those fears. And so if that person should feel suicidal, they'll be more capable of persisting through those fears and making a suicide attempt. For me, the example that works best, although I don't know if Joyner ever gave it, is someone with a history of non-suicidal self-injury.
Whether or not that person realizes it, they have a lot of experience self-inflicting pain and injury. And so it'll be easier for them to make a jump and make a suicide attempt than somebody else should they feel suicidal. A lot of people who self-injure don't feel suicidal.
A lot of people who self-injure will experience suicidal ideation. And there's just many other aspects involved. But that's all about acquired capability.
What my theory acknowledges explicitly is that there's also dispositional contributors to capability. Sometimes we're just sort of genetically have a lower or higher pain threshold, lower or higher on harm avoidance, just lower or higher on fears of things like death. And what I think matters most is practical, what we call practical capability.
So the most obvious example of that is access to a weapon or a firearm or some sort of means of death. But it goes way beyond access. It certainly involves knowledge.
I'll pause for a moment, but there's a lot I can say to expand the universe of practical capability. But I'll pause for the moment just to see where it makes sense to go to next.
Well, I'm not sure. So I think that there are, what I'm hearing are sort of two directions, two paths to capability. So one being a general comfort with death or related experiences.
So the idea of I have a high threshold of pain so that I can, you know, that increases my ability to act on my suicidality because if I had a low threshold of pain, I'd be much more hesitant to, or just the idea of, just a comfort with the idea of death versus more, you know, discomfort with the idea. So there's that aspect of capability, but then you're bringing up a second path here, which is also, so availability of means. Do I have access to the way that I would attempt to, attempt to take my life?
And also, along the same lines, do I just have the knowledge of how I could do this? That's sort of what I'm hearing.
Yeah, yeah. I mean, I would say that there's, at this moment, at least, I might even break practical into three pieces. One is you just have to have ideas, which isn't knowledge yet, and ideas that feel actionable.
Then there's, you know, well, do you have the means to do it like already? And then there's the knowledge to use those means. So like, you know, one example of that is, if we imagine two men who have equal suicidal desire and equal access to lethal means, absolutely identical suicidal desire, identical access to a firearm.
But one of them has used that firearm a lot. Like, they know exactly how it works, how to load it, how to pull the trigger, you know, what the recoil is like. And the other person just hasn't actually fired it before.
So they're not exactly sure how it works. If I pull the trigger, like, well, it jolted my hand. I think that person is going to be a lot more afraid to do it.
Like, will it go wrong? Will I just grievously injure myself? I don't know how this works.
So note that in this example, even though we held suicidal desire exactly constant and we held access to lethal means exactly constant, I think the first person is way higher on capability than the second person. Capability can also change fast. You know, if there's, like, an adolescent who feels suicidal and they learn on the internet that Tylenol is lethal in overdose but not Advil, from the perspective of the theory, their practical capability has just gone up quite a bit.
And I can give lots of other examples of sort of practical capability to sort of help expand the universe beyond simply access to lethal means.
Yeah, I think that that would be helpful if you wouldn't mind because I'm thinking that particularly for folks out there who are working with clients, that it could be really helpful to have a sense of what are the things that I might inquire about.
Yeah, so I'll give an example that might be a little of a hypothetical clinical anecdote where you have someone who's maybe been suicidal in the past, maybe right now they're not suicidal as far as you can tell, but they come into session and they tell you like, you know, the other day I was feeling like kind of all existential and like sentimental and like about life. And I wasn't like feeling suicidal, but I kind of like walked out to this bridge where I know some people have died by suicide. And I kind of like walked to the edge and I peered over and I thought about my life and all the stuff I've been to.
And, you know, and then after a little while, I just walked back home. And it was just a really interesting experience, so I wanted to share it. You know, of course, a therapist might ask, you know, just want to check in, are you feeling suicidal now?
And in this scenario, the client is saying, no, you know, I'm not, that's not what this was about. But from the perspective of the theory, this person's capability has gone up because it's now in their behavioral repertoire to walk to this bridge, where if, assuming before, they hadn't done it. So should this person feel suicidal, and if the bridge is an idea of how they might do it, it's now, there's a shorter distance, cognitively, emotionally, behaviorally, to just doing that than there was before.
So if, for example, you have a safety plan with this person, maybe now you modify the safety plan. You know, I'm glad you're feeling good now. I just want to bring to your attention, though, that, like, if you did feel suicidal, the idea that walking to this bridge is kind of easy could just sort of make an attempt to happen faster.
So, you know, it could be even a little bit scary to think about. Maybe let's fold into your safety plan. Should you feel suicidal?
Should you find yourself heading to this bridge? Let's have some concrete action steps that you can take. So that's one example.
Should I give another or should I pause?
Go for it. Let's have another.
You know, there's some data that anesthesiologists have higher suicide rates. And I think, you know, when people hear that kind of thing, they'll think things like, oh, like, you know, what makes them life worse for them? Maybe they want it to be like ER docs or surgeons, or like some sort of higher, you know, status doctor, but they couldn't do it.
And, you know, this is an example of someone. That line of thinking is instinctively thinking on the ideation end or the ideation to action framework. I suspect what's really happening with anesthesiologists in this case is that even if ideation rates are the same as everyone else, anesthesiologists are walking around with exquisitely high capability.
They have, of course, lots of access to drugs that could be lethal in overdoses. Not only that, they have access to drugs that can sort of like dull the senses. So if fear is a barrier, they can sort of have something that will calm themself down and then take something else.
And of course, they have exquisite knowledge. It's not just the access, they have exquisite knowledge. So it's sort of like the ultimate pairing of access and knowledge, the things that make suicide easier.
So their capability is extremely high. So that's just another example of how capability might come into play and just the way we should think about capability, I think, when it comes to suicide risk.
I don't know how to articulate it. Going down this road where you're talking about having access to means, then also this specific knowledge, it's a very different, I want to say factor, it's a very different category, a way of this stuff that contributes to the probability of people attempting or dying by suicide is sort of this stuff that has nothing to do, likely, maybe nothing to do with anything else that is contributing to their suicidality, that a person, an anesthesiologist could have, has exquisite knowledge and capacity, I'm sorry, access, knowledge and access, which could dramatically influence the probability that that person would die by suicide. And that is completely separate, right?
That is completely independent from, likely, from all of the other factors that are contributing to their suicidality.
Hence, the ideation action framework. Exactly. I mean, just a stat that I think brings us home is that in the United States, where firearms are more prevalent, households that own firearms have suicide rates three to five times higher than households without firearm ownership, even though there's no evidence that mental illness is higher in those households.
I think in some ways, it's when you reach your worst moment of overwhelming pain and hopelessness, you want the person to have a firearm in their hands, or would you prefer that they don't? It just turns out that you're more likely to die by suicide if in that worst moment you have a firearm or some other combination of high practical capability.
The next thing I wanted to get into was, you gave me a very nice lead in the Mental Illness Suicide Association, but before we leave the three-step theory, I just wanted to check to see if there's anything else you wanted to highlight or hit.
It's a good question. There's so much stuff I like to highlight or hit when I'm actually presenting it formally. If people are really interested in this, I'd point them to a 2021 paper on the theory where I really try to sort of unpack the nuance and hit a lot of the things that people think it sounds oversimplified just because whatever their exposure was didn't flush it out.
It was an abstract. It was a podcast. So if you're really interested in the theory, I think that's the best paper that sort of tries to anticipate the kinds of questions people have, the kinds of assumptions that are not quite right.
As someone writing something, I always have to take full responsibility when people are not getting the messages. So I'm trying hard and harder to get that, but some of the obstacles are just difficult. Like the word pain has connotations for some people that it doesn't have for other people.
Aversiveness, same thing. So even just the language used will tend to push people in certain directions that are not always what the theory means. So I've done my best in that 2021 paper to try to really, really flush it out and anticipate all these potential misunderstandings and get it right.
So how about if once we finish recording, I'll grab the citation for that. I probably already have the paper, but we'll double check. I'll grab the citation and put it in the show notes.
And if I am so tech savvy, maybe I'll figure out a way to be able to directly link to the paper. But at the very least get the citation out there. Great.
So tell me about this. I think oftentimes in media we think about mental illness leads or could lead to suicide or people are suicidal because they have mental illness. Is it that causal?
Well, from the perspective of the theory, suicidal desire begins with overwhelming pain and hopelessness. And so mental illness, especially when it's severe, especially when it's persistent, there's a great way to get to that point. But it's certainly not the only way.
So then how do you think about this, the association between certain mental illnesses and suicide?
I mean, I think it's a very simple but fairly accurate statement that the mental illnesses that most cause pain and hopelessness and disconnection and increased capability are the ones that are most associated with suicide risk.
Hence, depression.
Yeah, depression, bipolar disorder. Yeah, also I think might even have higher rates. But if you are chronically depressed or you have bipolar disorder that's really impacting your life, there's a lot of just pain, aversiveness, misery that just come from the depression or depressive episodes themselves.
That ends up having... There's other areas of your life that get impacted though. It's harder to create or maintain good relationships when you're sort of dealing with that.
When these things over time don't get better, you start to feel in the beginning, you're just like, maybe the medication will help, maybe this new relationship. But enough time goes by and you're like, this is just not getting better. You can lose hope.
So they're just... It just caused a lot of pain and a lot of hopelessness and a lot of problems with connection. And there's some ways where some of these things, not most of them, but some mental illnesses also come with increased capability.
So that's why they're such pernicious predictors of suicide ideation attempts and death.
For example, in terms of the increased capability?
There's some evidence that post-traumatic stress disorder not only... I'll back up one step. Depression, for example, including depressive disorders, is a very strong predictor of having experienced suicidal ideation.
But it's not meaningfully... People who have attempted suicide are not meaningfully higher on depression compared to people who have seriously considered suicide but not attempted. So depression definitely gets you to a very high likelihood of feeling suicidal.
It's one of the strongest predictors of feeling suicidal. But among people who feel suicidal, depression doesn't seem to further predict whether or not you attempt. And that's probably because it doesn't increase capability.
It can get you to step one and step two, but it doesn't do step three. Posttraumatic stress disorder actually seems to also distinguish people who have attempted from people who have considered suicide without attempting. We're sort of in educated guest territory here as opposed to solid data.
But my guess is what's happening is posttraumatic stress disorder comes with experiences of trauma, often actual or threats of physical harm. And you sort of enforced, obviously, through no choice of your own to endure those things. Plus you have a lot of re-experiencing that you sort of are forced to deal with.
And so the guess is that sometimes dissociating, dissociation comes with those kinds of things, which might actually paradoxically sort of make them easier to tolerate. It might be almost like your body's way of coping. And so those things might actually increase one's capability to persist through the kinds of fears that are barriers to attempting suicide.
And so empirically, post-traumatic stress disorder seems to also distinguish attempters from ideators, unlike depression. Non-suicidal self-injury is another example that seems to do that. I know that's not like a formal diagnosis, but non-suicidal self-injury seems to increase risk both for feeling suicidal, because it's like a marker for high distress, but also for progressing from ideation to attempts because it probably has a causal impact on capability.
So then when you're thinking about what leads to suicide.
How do you think we should be thinking about mental illness versus or in concert with these factors that are part of the theory?
I think we should understand that pain and hopelessness are what motivate suicide, and that mental illness plays a role to the extent it does those things, but other things also can do that. If someone, I'll just use maybe a stereotypical example of the executive of a company who suddenly something terrible has happened and they're in tremendous debt, and maybe their reputation is going to get shamed. And so in that moment, it could be so overwhelming that they've lost everything that matters to them.
They'll be shamed in the eyes of their family and everyone who is in their world. They don't see a way out of it. This can bring up pain hopelessness and pain dwarfing connection really fast.
And so if their capability is sufficient, they might go from not meeting any conditions for the theory steps to meeting all of them very quickly and die by suicide. I don't think they developed a mental illness in that short period of time. I think they were a human who in that situation had all those things spike and also maybe had the unfortunate case of having capability that was sufficient in that moment too.
Otherwise, they might have survived that moment. You know, there's some evidence, it's very hard to have good evidence, but there's some evidence that suicide rates were extremely high in the World War II concentration camps. I don't think there's any reason to believe that that's like, oh, if they just had more access to antidepressant medications, they would have been better.
I mean, I think they were in a situation that naturally made pain and hopelessness extremely high, and eventually to a point where either your connections were taken away, literally, or you're just in so much overwhelming pain, you just can't appreciate the connection. So like, I think there's life circumstances that can make these things very high that are not mental illness, but mental illness is also a very powerful cause of the three-step theory factors.
So we've talked a lot, and I think as we're winding down, a lot of what you said has implications and hopefully will be helpful for clinicians working with folks who are suicidal. Are there any other considerations that you want to throw out there before we end, or any other points you want to make specifically to clinicians?
Well, maybe that I want to acknowledge that we over-prioritize prediction when it comes to suicide risk, because the answers to step one, two, and three, is there pain and hopelessness, is there pain an overwhelming connection, is there capability, those ebb and flow over time. The answer that someone gives at one point, you can't predict whose pain is next going to recede because maybe the loved one they thought was leaving them is now comforting them, or whatever other circumstance we can come up with. We can't predict who will next experience overwhelming pain and then the other factors.
That's just the way the world works. So this information is not particularly helpful for predicting because those conditions ebb and flow over time. We just have to acknowledge that that's true.
I have a one-hour talk on how in suicide we conflate prediction with understanding and prevention. So we're not going to have time to get into all of it. But what I will note is that when you look at things like heart disease and stroke, we're very bad at predicting.
You can't have a doctor evaluate someone and then know with confidence this person is going to have a heart attack in the next week. All we know is broadly speaking, risk is higher. And yet, we've done very well at improving prevention for those conditions.
And I can even take a behavioral example like drunk driving, where over the last 30 years, give or take, we've reduced drunk driving fatalities in North America by about half. We're not sort of trying to predict who's going to drive drunk next. We just have a very practical understanding of the conditions that bring about drunk driving, you know, presence of alcohol, not planning ahead, allowing people to drive home drunk.
And we just wrap prevention into those conditions. So we have things like designated driver, friends don't let friends drive drunk, ride share apps. So prediction is not prevention, and prediction is not even understanding, because we can understand the conditions that bring about, we can understand very well the conditions that bring about heart attacks.
We can understand very well the conditions that bring about drunk driving, but we can't predict any of them very well. The same is true for suicide, we can't predict. We can know broadly speaking who's at risk, and then we can wrap prevention around those causes.
And so I think that's what we have to understand, is we can't predict, but we can wrap prevention around those causes. And if you understand someone's pain, hopelessness, connection, and capability at a given moment, you understand their suicide risk, and you can use your clinical skills, your experience, your armory of tools to address those.
Right, so then what I'm hearing you say is that for the clinician, it's about attending to these, attending to pain, attending to hopelessness, attending to a person's perceived connectedness, which is sort of fits well within the purview of most helping professionals, that these are things that outside of suicide that we deal with all the time, and have different approaches and different frameworks for dealing with them, but that's those factors that contribute to suicidality. This gives you targets for your intervention, rather than just suicidality broadly or nebulously.
Yeah, that's right. Of course, a lot of what we do in intervention is at least implicitly meant to improve these things, but I think there's value in being more explicit both of their understanding. What I really hope is that when I give my talks on the three-step theory, I just generally don't know if a podcast version works or not.
I think the talks do. I hope the paper does. It actually leaves people feeling like, oh, I understand suicide better.
I get that feedback a lot, and that's my goal. I just want people, I want to take it from this black box scary thing to like, oh, I understand this now in the context of intuitive human principles of human nature, and that understanding is empowering and actionable. So then it allows us to be more explicit first in just knowing what's happening with our client.
Why are they feeling suicidal now and not then? It's like, oh, something's changed. What is it?
Pain's higher. They had hope last week, but now they're feeling hopeless. It just empowers us to know how to think about suicide risk and then what to do in a more explicit way.
Well, I can say personally that this has been very enlightening for me, that I think it, being able to hear you talk about it and sort of respond to my questions, my naive perceptions of things has actually, you know, I've learned quite a bit in this conversation. And in our conversation also, as I indicated, I feel like there were several times where you made several comments where I was like, oh, that has clinical implications. Oh, that has clinical implications.
That I could sort of, you know, it didn't take too much imagination on my part to see those links.
Oh, I'm really glad to hear that. I mean, because that's my goal. A lot of times you're like, okay, now you have to turn this into like the treatment.
I'm like, well, but how you do this for a school versus a child versus an adult, like it just in the context of substance use, like it just, it's different. It's like, have you stopped drunk driving? Well, it depends.
You need to know more first. So what I really want is people to have an understanding and then feel like, oh, okay, that makes that makes my understanding better. And I know how to use that information.
So there's almost nothing that makes me happier than hearing someone like you say that because you will know better than me how to apply it. Like, and I mean that as genuinely as I can, you will know better than me how to apply it to your context. And if I've given you that feeling that you have stuff that you can use this, oh, I'm so grateful.
So thank you for saying that.
Well, thank you. I mean, this has been really, I think it's been great. So we'll do a fake sign off here.
We'll all stop recording and we'll touch base at the end. But for, you know, the for social norms, thank you, David. I really appreciate it.
It's been wonderful chatting with you.
Oh, thank you. It's a really fun opportunity and yeah, really enjoyed it. Thank you.
First off, I want to extend my sincere thanks to Dr. David Klonsky for joining us today. It was an insightful conversation and I'm delighted we could share it with you. If today's episode peaked your interest, why not pass it on to someone else who would appreciate it too?
We have some truly exceptional guests lined up that I'm excited for you to hear from. Until then.
First off, I want to extend my sincere thanks to Dr. David Klonsky for joining us today. It was an insightful conversation and I'm delighted we could share it with you. If today's episode peaked your interest, why not pass it on to someone else who would appreciate it too?
We have some truly exceptional guests lined up that I'm excited for you to hear from. Until then.