Why Suicidal Thoughts Don’t Always Lead to Action with Dr. David Klonsky (Encore)

Revisit our conversation with Dr. David Klonsky, Professor in the Department of Psychology at the University of British Columbia studying suicide, the parsimonious models of suicide, and the better understanding of suicide motivations and warning signs.

Dr. Klonsky dives deep into the Three-Step Theory of Suicide, explaining why some people consider suicide and some attempt suicide. He shares his experience in martial arts and how it has influenced his understanding of the mental and emotional aspects of fighting. Dr. Klonsky explains the three-step theory which includes the conditions under which people feel suicidal, the intensity of suicidal desire, the capability to attempt suicide, and more.

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

For more episodes, video versions, updates, and links related to the show visit:
https://psychotherapyandappliedpsychology.com/

Transcript

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[Music] A large part of my job is training the next generation of mental health practitioners. Because of this and because I do research on suicide, I often find myself in conversations about how clinicians should understand and respond to clients who are contemplating taking their own life. So today we're going to have a re-release of one of our early and most listened two episodes. This conversation my guest walks us through the three step theory of suicide and helps make sense of why suicidal thoughts develop, why they intensify, and why some people act on them while others do not. We talk about pain, hopelessness, connectedness, capability, and why prediction is not the same thing as prevention. And for clinicians, this conversation offers a practical way of thinking about suicide that's less mysterious, less fear driven, and more actionable. But first, if you're new here, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to psychotherapy and applied psychology where I sit down with leading researchers to pull out practical insights, peek behind the curtain, and hopefully have a little bit of fun along the way. If you're getting value from the show, do me a huge favor and subscribe on your podcast player, or if you're watching on YouTube, hit like and subscribe. It's one of the simplest ways to support the podcast and keep these conversations going. This episode starts with my guest responding to my question about how he got into studying suicide. So without further ado, my very special guest, Dr. David Klonski. I mean, the truth is, is a little bit accidentally. The interest that was more organic was non-tuosidyl self-indry. And I remember the first time I learned about an SSI non-tuosidyl self-indry in undergraduate. I was just finding it inherently interesting because it just sort of goes against, you know, if you don't have experience with it, it goes against your intuitive sense of how people work. You know, we want to avoid pain. So why do some people, and some occasions, you know, self-inflicted pain and injury. And it registered, but I didn't really do anything with it. And in grad school, one of my early clinical practicup, I was, I encountered someone with schizophrenia diagnosis in a hospital, but who also had a self-indry history. And at the time, DSM-4 said self-indries, borderline personality disorder. So I asked my clinical supervisor, like, how often does someone without borderline personality disorder have self-indry? And they said, it's a good question. I don't know. And then I said, well, does everyone who's self-inders, like 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 and herally interesting. I think I was, 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-indring the diagnostic manual and just how it manifested. Just seeing, you know, so that was the sort of intellectual side of it. And on the sort of more emotional side of it, you know, I definitely, you know, most people I'm guessing have various kinds of distress that are hard for them. You know, depression is hard for a lot of people. Because I had used hard for a lot of people. For me, it was mainly anxiety and sort of a sense of socially feeling like I knew the social rules. And those are real struggle. And so just my interest in psychology in general was just like wanting to understand this better, like understand people better, understand the human condition better. And 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 like, 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-indry is just undoubtedly real. You know, it's this it's an actual behavior. It's it's there's no denying that it's a real thing for a lot of people comes with this stress. 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 by myself. But you know, if I am 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-indry became my primary area of focus in graduate school, even though it was not my advisor's focus. But then very long explanation to get to suicide. You can't study before before we before we go there just real fast. Can you just what is non suicidal self injury and how do we differentiate it from suicidal self injury? Non-suacidal self injury, probably the most typical behavior people hear about is like cutting the skin, but you can take other forms, you know, 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 and not everyone agree with that. People love to see self injury and suicide is like 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 is distinct from suicide attempts, which also meant at the time I was running to 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. So 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 lay person's intuition of how people should operate. And these are people who deserve a need understanding. And so, you know, and these behaviors are undeniably real and concrete all that together just I guess made them a fit for for you to want to put my energy into understanding them better. So I interrupted when you were when you were really going down the road of how you got into studying suicide. And the answer is as I was I was studying on suicidal self injury, I guess this is mid 2000s and then but over and over again people then want to know what does relationship is suicide. And so then I started, you know, wanting to understand that too. Now something, you know, 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, you know, 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 advisors focus wasn't 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 they 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 when I saw it was my very first independent grant other than a grad school one from. And I remember I like 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 2000 military recruits. And we happened in that data set to have measures that 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 and be described 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 who 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. That 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 were 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's simple civility is the quintessential personality trait that determines who acts on these kinds of thoughts and who doesn't. And so, you know, it was an unanticipated finding, but you know, I was ready to embrace it. The data are the data. And that ended up raising a whole bunch of other questions and I've sort of never, 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 that's impulsive ends up just being a synonym for didn't see it coming. It's not a mechanism when people when what people try to say something is impulsive with the really trying to say something about the mechanism. The reason. And it doesn't work on that level. If you're using impulsive justice sort of like a descriptive term of like we didn't see it coming or the person didn't see it coming. And yes, things can be impulsive. That's not the explanations. So to put 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 a middle of this podcast and your thirst that 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 and that doesn't make you impulsive. So, you know, descriptively, you'd be an impulsive water drinker, but mechanistically, the 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, you know, 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. So, those are separate processes with separate explanations and separate predictors. So, you know, if I want to explain why someone's feeling suicidal, that will be different explanation, then 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 that we 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 it potentially lethal suicide. 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 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's steps, but sometimes it's not. It could be very non-linear. So, for example, if 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 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. And though embedded in every paper I write about it, our example is 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, 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. No, it's actually not true. 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 step, the answer is when two conditions are met, people are experiencing overwhelming pain, usually psychological 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, 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 then 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, but I think 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. Now, I'll stay 30,000, resist the urge to clarify all the pieces. So if you're experiencing, you know, 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 Evan 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 where as pain is that is the push from being alive and that applies the first thing we should talk about when we cycle back. Connectingness is what can make a very painful existence feel worth it. But if your pain is, you know, dwarfing your connection to life, or in some cases when pain is so severe, sort of just takes away your ability to engage or appreciate connection to otherwise what have, then not only are you an intense pain and feeling hopeless at 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 attempt to lethal suicide attempt and it's an important question because most people who feel feel suicidal do not attempt most instances of suicidal desire do not lead to an attempt. So under what conditions the 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 joiner 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 with 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 in the over experiencing overwhelming pain and hopelessness. If yes, you'll feel suicidal ideation, if not, you will not. Is your pain, seating or overwhelming your connectedness, if not your ideation will be modest or occasional, if it is your ideation strong. And finally, if 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 with 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'll be helpful. Then when we dig into it, people have a larger context in which sort of 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, what 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 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 will keep living. You'll keep living if you follow certain rules. We have steep belts and all sorts of fire codes. We just wrap anti death measures into all aspects of human life. 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. 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 ones to do that. So this is just, we are very much behavioral creatures. If something is reward paired with reward, we want to do more of something as paired with punishment. We want to do it less. This is also fundamental. And so if someone is experiencing a life, it is painful, it is miserable, it is aversive. That same instinct kicks in that I don't want this anymore. So to 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. 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 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 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. Or re-conceptualization of pain, you sort of made me think in a way I haven't thought before that. I mean, I do think typically, 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 mean 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. Yeah, I like to term a versiveness, but I was convinced that that was too, had too many syllables. Say more about that. Well, it's anything that's aversive, we don't want to deal with it anymore. And it really is, I mean, it's 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 in a severe, I mean, they could be the overwhelming financial pressures that just don't have 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're saying changing your language from pain to aversive, it expanded my thinking. As soon as you said that, I had a different framework for things. I mean, slightly, different framework for thinking about it. Because aversive is, 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 manifestation being clearly like equivalent to some sort of a pain. I don't know, it just broadened my thinking. Yeah, I mean, I 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're 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. Even 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. And 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 what you knew that it was temporal that it was or that it was going to be short lived. Right. But when you don't see a light at the end of the tunnel, that 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 aversive matters. Like, you know, it's not literally like any tiny little thing just that's aversive that doesn't necessarily make life feel aversive. I quite enjoy life, you know, even when I have deadlines or where I might have some mixed feelings like there's some, you know, the overall life is a six out of 10 on life satisfaction. 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's had 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's 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 going to change? That's the combination that makes someone feel like maybe being alive is not for me. So do you think about hopelessness as it, 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 hopeless, or I'm sorry, high aversiveness and high hopelessness is where you get into trouble. Or start to experience it, experience suicidal desire. Do you think that that hopelessness contributes to the aversiveness, that makes sense? Yeah, definitely. I mean, you know, hopeless doesn't feel good to feel hopeless. It's aversive, you know, cognitive effect 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, you know, these psychological factors can inform each other. Really, I'm just trying to specify the necessary conditions from my perspective that bring about suicidal desire. And then according to those necessary conditions, being in a hopelessness don't have to have causal impacts on each other. But of course, you know, 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 any 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. Connecting this can be to social kinds that were used to thinking about, you know, friends, family, level, and partners. But we also acknowledge it could be to community. It could be to a sense of identity. It could be to, you know, to a pet. It could be to cause that you believe in. It could even, it really a connection to any sense of meaning or purpose is a count 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, you know, 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 would life's aversive? Like that's the push that I don't want this anymore. I, you know, either I don't want it anymore because I'm going to create a better future or I don't want 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 pulp 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're 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 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 aversive. I've no way out of this. There's nothing and there's nothing that makes it worth it. You know, that's one that's who is how desire to become stronger. So connection gives me, gives me purpose because you mean it 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 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. It matters to you. Yeah, that gives you a sense of meaning and purpose. Yeah, there's a, 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 seasons 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'm at the side of 10 my life. So it could be a favorite TV show, you know, that you look forward to seeing, you know, just something that you feel connected to that brings enjoyment that pairs life with positive. So the, 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 they 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 hope it, 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 temporarily, but logically. 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 for 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 those things are different. So 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 the question right now. Let's see. Well, I mean, if your life is painful, miserable, aversive, like let's say you first year grad school, and it's like you're in a new place, you're not friends, everything's stressful. But if you have every sense of like, you know, things will get better with time. I'll get you know, learn how it works. Meet new friends. Then you know, 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 a suicidal? We don't even have to worry about the other conditions in terms of how you're feeling at this moment. Now, 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, if you should develop suicidal desire. But in terms of the part of the theory we're focusing on now, that person will 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 is, 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, ah, sucks. I don't really want to be alive. But you have high connection. Then you have another piece that connections 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 step to the point where it's to step to 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 am, 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, you know, again, it's the theory is just the necessary conditions. But why people feel pain could be, could be, innimly tied to connections. I mean, for some people, it can happen fast. So, you're a significant relationship and 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, you know, because your future was tied in your mind to this person. And now your main connection is gone. So, you know, 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 that can come from a chronic illness that's just getting more and more painful. And it makes day to day life like you're just always suffering. And every day is more suffering. You know, 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 aversive. 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's I'm just in pain. And so those also are ingredients that can 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. Right? 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? It's not so. Yeah. High pain. Hi, I'm sorry. Hi, let's use a version. Hi 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, that's that's it's nothing that makes it worth it. And then that and then getting to step three. So step three, being where folks will have, you know, they go from that strong suicidal desire to actually an attempt is that capabilities on joiner, I think, could say acquire capability or capability for suicide. So you could could you unpack that a little bit. Yeah, joiner introduced acquired, but all of us, including joiner have expanded capability far beyond acquired at this point. I don't know if joiner ever formally did it, but you can see in what he writes, how he is, you know, way beyond acquired. And he at least said, I'm trying to remember what the format was. I don't know if he has written it or just said it, but he said that he really regrets calling it acquired. You should just call the capability. So yeah, the idea is 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 is very hard to overcome those barriers. And so joiner 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. This 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. You know what are examples of these painful provocative events? I mean, it could be like a firefighter who is always rushing towards, you know, potential death and even being around people who have died or have that 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, there will 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 joiner 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, you know, 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 injured don't feel suicidal. A lot of people who self injured 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 higher pain threshold, a lower higher on harm avoidance, you just lower higher on fears of things like death. 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 fire arm or some sort of means of death, but it goes way beyond access that certainly involves knowledge. I'll pause for a moment, but there's a lot I can say to expand the University of Practical Capability. I'll pause for a moment just to see where it makes sense to go to next. Well, I'm not sure. So I think that there are, when I'm hearing 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 comfort with the idea of death versus more discomfort with the eye. So there's that aspect of capability, but then you're bring up a second path here, which is also so availability of means. So I'm going to be able to access to the way that I would attempt to attempt to take my life. And also a 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 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. That feel actionable. Then there's, you know, 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 a, if we imagine to, to men who have equal suicidal desire and equal access to lethal means absolutely identical suicidal desire identical access to firearm. But one of them has used that firearm a lot like they know exactly how it works, how loaded 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. Well, if I pull the trigger like, well, it jolt in my hand. I think that person's going to be a lot more afraid to do it. Like, will it go wrong? I just eat grievously injure myself. I don't know how this works. So note that in this example, even though we held to desire exactly constant and we held access to lethal means exactly constant. I think the first person is way higher on capability in 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 and 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 sort of help expand the universe beyond simply access to lethal means. Yeah, I think that that would be helpful if you 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 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. Right now 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 I wanted to share it. You know, of course a therapist might ask her, you know, just want to check in or you feeling suicidal now and the scenario the client saying, no, you know, I'm not that 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 behavior 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 you did feel suicidal, the idea that walk into this bridge is kind of easy, sort of making it kind of fast. So you know, so leaving 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 something concrete action steps that you can take. That's one example. Should I give another or should I pause go for another. There's some data that anesthesiologists have higher suicide rates and I think when people hear that kind of thing, they'll think things like, oh, what makes them life worse for that maybe they wanted to be like, er docs or surgeons or some sort of higher. You know, status, doctor, but they couldn't do it. And, and you know, this is an example of someone that line of thinking is instinctively thinking on the ideation and of the ideation to action framework. I suspect what what's really happening with anesthesiologist 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 that could be lethal and overdoses. Not only that, they have access to drugs that can sort of like dull the senses. So if fears a barrier, they can sort of have something that will calm themselves down and then pick something else. And of course, they have exquisite knowledge, such as 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 capabilities extremely high. So that's just another example of how, you know, capability might, you know, might come into play and how 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, where you're talking about, you know, having access to means that also this specific knowledge. It's almost, it's a very different, I want to say factor, it's a very different category, a way of like this stuff that contributes to the probability of people attempting or dying by suicide. It's 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, you know, 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, that is completely separate, right, that is completely independent from likely from all of the other factors that are contributing to their suicide, suicide. Hence the ideation action framework. Exactly. I mean, just a stat that I think brings this home is that in the United States where firearms are more prevalent households that own firearms have suicide rates three to five times higher and households without suit fire arm ownership, even though there's no evidence that mental illnesses higher in those households. I think it's, you know, in some ways is when you reach your worst moment of overwhelming pain and hopelessness, do 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. So I want to, the next thing I wanted to get into was you sort of 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 and there's, you know, the people are really interested in this. I'd point them to a 2021 paper on the theory where I really tried to sort of unpack the nuance and hit a lot of the, a lot of the things that people think it sounds oversimplified are just because whatever their exposure was didn't flush it out, you know, it was an abstract. It was a podcast. So, you know, 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. You know, 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. The word pain means as connotations for some people that they walk doesn't have for other people, a versiveness, 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, once we finish recording, I'll grab the citation for that. I probably already have the paper, but I'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 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 of suicidal because they have mental illness. Is it that causal? So the perspective of the theory, you know, every suicidal desire begins with overwhelming pain and hopelessness. And so mental illness, especially when it's severe, especially when it's persistent is 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. Depression bipolar disorder. Yeah, also, I think may even have higher rates. Yeah, but you know, if you are chronically depressed or you have bipolar disorder that's really impacting your life. There's a lot of just pain, a versiveness, misery that just comes from the depression or the press of episodes themselves. And so it ends up having, you know, there's other areas of your life that get impacted though. It's harder to have 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, you know, 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, it's just not getting better. You can lose hope. And so that's just, you know, just, you know, it's just a lot of pain and a lot of hopelessness and a lot of problems with connection and there's some, 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 there's such a pernicious predictors of suicide ideation attempts and death. In terms of the increased capability. There's some evidence that post-traumatic stress disorder, not only, or backup one step depression, for example, including the press of 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've seriously considered suicide, but not attempted. So depression definitely gets you to very high likelihood of feeling suicidal. So it's one of the strongest predictors of feeling suicidal, but among people who feel suicidal, depression doesn't seem to further predict whether you, whether or not you attempt. It's not necessarily because it doesn't increase capability. It can get you to step one and step two, but it doesn't do step three. Post-traumatic stress disorder actually seems to also distinguish people who've attempted from people who've 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 post-traumatic 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. And 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, maybe like almost like your body's way of coping. So those things might actually increase the capability, one's capability to persist through those kinds of fears that are barriers to attempting suicide. And so empirically, post-traumatic stress disorder seems to also distinguish temperatures from ideators unlike depression. And non-tuosalousyl fenders and other example that seems to do that, I know that's not like a formal diagnosis, but non-tuosalousyl fenders 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's sort of probably has a causal impact on capability. So then when you're thinking about sort of what leads to suicide, where do you think we should be, 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 about 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, you know, how it just sees maybe a stereotypical example of like the executive of a company who suddenly something terrible has happened and they're in tremendous debt and maybe they're also the 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's in their world. They don't see a way out of it. You know, this can bring up pain, hopelessness and dwarfing, you know, pain, dwarfing connection really fast. And so if they're a capability sufficient, they might go from, you know, not meeting any conditions for the theory steps to meeting all of them very quickly and die of a 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, you know, 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 it's like, oh, they just, 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 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 very powerful cause of the three step theory factors. So we've talked a lot and I think I've 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, 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 prioritized prediction when it comes to suicide risk because the answer is to step one, two and three. You know, is there pain and hopelessness is pain overwhelming connection is a 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 love one they thought was leaving them is not comforting them or whatever other circumstance we can come up with. And 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 can those conditions ever flow over time we just have to acknowledge that that's true. I have a one hour talk on how in suicide we can flate 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 and is 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 friend to my friends drive down 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 as 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 that's 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 or suicide risk. And 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 that's those those factors that contribute to suicide and this gives you I give you targets for your intervention rather than just suicidality broadly or nebulously. Yeah that's right I mean of course a lot of what we do intervention is at least implicitly meant to improve these things but I think there's value in being more explicit both of the understanding like what I really hope is that when I give my talks on the three step theory and I don't 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 and just knowing what's happening with 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 were hopeless they were they had hope last week but now they're fulfilling 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 is clinical implications oh that is 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 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 start drunk driving all 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 is genuinely as I can you will know better than me how to apply it to your context and that 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. Ladies and gentlemen Dr David Klonski that's a wrap on our conversation as I noted at the top of the show be much appreciated if you spread the word to anyone else who you think might enjoy it until next time.[Music]