World Suicide Prevention Month: Overview of Ideation-to-Action Theories
Welcome to World Suicide Prevention Month. Over the next few weeks, I will be sharing scientific research on suicide ideation, attempts, and recovery through an accessible lens. Join the conversation!
Ideation-to-Action Theories: Rationale
According to data from the World Health Survey, 9.2% of adults in the general population think about dying by suicide (suicide ideation), 3.1% form a plan for attempting suicide, and 2.7% attempt suicide. While historical research on suicide risk has focused on comparing those who have attempted suicide to controls (those who have never attempted suicide), current research is focusing on comparing controls, ideators (those who think about suicide but haven't attempted) and those who have made an attempt.
This research is termed ideation-to-action because it seeks to understand the formation of suicidal thoughts and the progression from thoughts to attempts. Four theories have emerged under this framework, and differ in how they propose ideation emerges and progresses to action: the Three-Step Theory (3ST), Interpersonal-Psychological Theory (IPTS), the Integrated Motivational-Volitional model (IMV) and the Fluid Vulnerability Theory (FVT).
These theories have been tested cross-sectionally by comparing controls, ideators and attempters; micro-longitudinally by observing changing levels of suicide ideation and behaviours over a short time period; and longitudinally to establish causal influence (i.e. pain causes ideation and capability causes attempts).
Rather than pitting theories against one another, it is useful to examine the contributions each theory has made to understanding the progression from ideation to attempts:
We now understand suicidal ideation to be the result of cognitive, emotional, and interpersonal vulnerabilities that weaken connection to living, and suicide attempts to occur when an individual overcomes natural aversions to death through dispositional, acquired, and practical capability for suicide.
We still struggle to predict suicide, but ideation-to-action models are useful for more than prediction. By understanding the factors that contribute to suicidal desire intensifying and leading to suicide attempts, we can target these factors in treatment. Knowing that connectedness applies to more than just interpersonal relationships (community, the earth, or a greater purpose) widens avenues by which a therapist can work to increase a patient's connectedness. Understanding capability for suicide through acquired, dispositional and practical factors has led to advances in means safety initiatives; reducing the availability of lethal means in the community.
My suicidal ideation fits well with all four theories. I have a cognitive propensity to think of suicide as an immediate solution when faced with unbearable stress, and my emotion regulation deficits put me at risk for prolonged and intense unbearable emotions often (IMV). I'm more vulnerable to experience negative emotions as unbearable (emotion regulation deficits) and more likely to cling to suicide as the only solution to my pain (cognitive inflexibility). Cognitive inflexibility also manifests as black and white thinking: I get so attached to a single picture of my future that I am unable to imagine a life worth living when I experience loss. Worth noting is that black and white thinking - or splitting - as a symptom of borderline personality disorder can devastate connectedness. I experience splitting with not only people but also communities, jobs, hobbies, and things that keep me tethered (3ST). Last fall I lost my job, but for me it also comprised my community, friendships, mentor, and passion. The pain I felt losing that job was so immense I struggled to go to classes at the same university or work at a different lab in the same building; my pain touched everything connected to my loss. One year later I am still struggling to rebuild my connections to living, to push past the things that remind me of my hurt in hope that I will manage to create new relationships, new passions, new communities.
1. Global prevalence of suicide ideation, plans, and attempts: Nock, M. K., Borges, G., Bromet, E. J., Alonso, J., Angermeyer, M., Beautrais, A., ... & De Graaf, R. (2008). Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. The British Journal of Psychiatry, 192, 98-105.
2. 3 Step Theory: Klonsky, E.D., May, A.M. (2015). The three-step theory (3ST): a new theory of suicide rooted in the “ideation-to-action” framework. Int J Cogn Ther, 8, 114-129.
3. Interpersonal-Psychological Theory of Suicide: Joiner, T.E. (2005). Why People Die by Suicide. Cambridge: Harvard University Press.
4. Integrated Motivational-Volitional Model: O’Connor, R.C. Towards an integrated motivational–volitional model of suicidal behaviour. In International Handbook of Suicide Prevention: Research, Policy and Practice. Edited by O’Connor RC, Platt S, Gordon J. 2011:181-198.
5. Fluid Vulnerability Theory: Rudd, M.D. (2006). Fluid vulnerability theory: a cognitive approach to understanding the process of acute and chronic risk. In Cognition and Suicide: Theory, Research, and Therapy. Edited by Ellis TE. Washington, DC: American Psychological Association.
6. Ideation-to-Action Overview: Klonsky, E. D., Saffer, B. Y., & Bryan, C. J. (2018). Ideation-to-action theories of suicide: a conceptual and empirical update. Current Opinion in Psychology, 22, 38-43.
7. Meta-analysis of IPTS: Ma, J., Batterham, P. J., Calear, A. L., & Han, J. (2016). A systematic review of the predictions of the Interpersonal–Psychological Theory of Suicidal Behavior. Clinical psychology review, 46, 34-45.
8. Micro-longitudinal evidence for FVT: Bryan, C. J., Rozek, D. C., Butner, J., & Rudd, M. D. (2019). Patterns of change in suicide ideation signal the recurrence of suicide attempts among high-risk psychiatric outpatients. Behaviour research and therapy.
9. Means safety to treat capability for suicide: Anestis, M. D., Law, K. C., Jin, H., Houtsma, C., Khazem, L. R., & Assavedo, B. L. (2017). Treating the capability for suicide: A vital and understudied frontier in suicide prevention. Suicide and Life‐Threatening Behavior, 47, 523-537.