by Michael D. Anestis, Ph.D.
Last night, I was having a conversation on Twitter during which an individual mentioned that a focus on means restriction - making it more difficult for individuals to gain access to highly lethal methods for suicide - is problematic because it doesn't focus on the "causes." He mentioned depression and hopelessness as causes, which makes sense in a lot of ways, but I would argue that this response is not only off base, but is also emblematic of a larger problem in how we think about suicide risk.
Over the past year or so, I've really shifted most of my work to explicitly consider what is referred to as the "ideation to action" framework. The phrase comes from David Klonsky and Alexis May (click here for a link to one of their great papers) and refers to the need for folks thinking about suicide risk to get away from building a never ending list of risk factors for suicide overall and instead to work on understanding what prompts suicidal ideation versus plans versus non-lethal attempts versus death and in what contexts those variable have the most influence. Another way of thinking about this is that they called for researchers to focus on moderators and mediators rather than simple main effects and to be more specific about the precise nature of their outcome variables.
To clarify why this is so important, think about it this way....
At any given moment, most people are not thinking about suicide
Unfortunately, however, a sizable minority are having such thoughts
Nonetheless, the vast majority of those individuals thinking about suicide will not make an attempt.
Taking it a step further, the vast majority of those who do attempt, will not die from that attempt.
As it turns out, we're not particularly good at determining ahead of time which individuals will end up in that final group - the folks who unfortunately die by suicide. In fact, recent work by Joe Franklin and others from Matt Nock's lab demonstrated that we're no better at predicting this now than we were in the middle of the last century. Think about that for a second....it's not good.
A major reason for this is that so much of our attention has been set on building a list of variables associated with "risk" overall rather than understanding the more nuanced relationships that lead to somebody moving from the largest group (no thoughts of suicide) to the smallest one (suicide decedent).
The things that prompt an individual to think about suicide are not necessarily the things that facilitate that individual transitioning from thoughts to attempt or death. Remember, most people never make that transition. Given two people - one who is depressed and one who is not - I would assume greater risk for eventual death by suicide in the depressed individual, but given two depressed individuals, I have no way of determining who is at greater risk and, by far, the most likely outcome is that neither will attempt or die. We need better information to understand that transition from ideation to action.
One way of thinking about this is using Joiner's Interpersonal Theory of Suicide (ITS). Joiner notes that serious or lethal suicidal behavior is only likely when both suicidal desire (driven by a sense of isolation, a belief that one's death is worth more to others than their continued life, and hopelessness that this will change) and the capability for suicide are present. Suicidal desire makes intuitive sense, but the capability part is a bit different. In Joiner's theory - and substantial research has now backed this up - the capability is comprised of an elevated tolerance of physical pain and a diminished fear of death and bodily harm. Suicide is scary - even when it is desired - and we are genetically programmed to try and survive. Persisting through catastrophic damage to our body in pursuit of death is something that most people simply (and thankfully) cannot do, which is one of the primary reasons why most individuals who think about suicide never attempt and most who attempt do not die. It's hard to do. Individuals need to either innately have the capability to do this or they need to develop it over time through repeated exposures to and experiences with events that change our relationship with death and pain (e.g., non-suicidal self-injury, prior suicide attempts, physical abuse, witnessing death).
So by thinking about whether, how, and in what contexts a variable contributes to the desire versus the capability for suicide, we position ourselves to better understand those who need help but are unlikely to die from those who need help and are at greater risk to themselves.
An example of this that we have looked at quite a bit in our lab recently is emotion dysregulation (click here for a link to a review paper summarizing this research). We have repeatedly found that individuals who are overwhelmed by, have difficulty identifying and tolerating, and feel the need to immediately escape negative emotions are more likely to think about suicide. That's not earth shattering news, but the more complicated part of that is that, in non-suicidal individuals, those same difficulties predict less capability for suicide and in individuals with prior suicide attempts, those difficulties are no longer associated with actual suicidal behavior once we consider the impact of other behaviors (e.g., non-suicidal self-injury) that emotionally dysregulated folks tend to engage in. That might sound a bit weird - after all, emotionally dysregulated individuals die by suicide at an elevated rate and a treatment with great success in reducing suicide risk (dialectical behavior therapy) focuses largely on increasing distress tolerance and building emotion regulation skills - but when you consider the ideation to action framework is makes quite a bit of sense. Being chronically overwhelmed by your emotions certainly prompt an individual to think about suicide or any other option that might seem to offer a way not to feel these distressing states. But remember, suicidal behavior is difficult, frightening, and often very painful. That type of behavior does not offer immediate relief....it requires someone to prioritize dying over immediate escape from discomfort. When you think about it that way, emotion dysregulation on its own might make someone less capable of suicidal behavior. Instead, they might choose another behavior that offers immediate relief without the same fear or required persistence like non-suicidal self-injury. But what if that individual engages in that behavior many times over an extended period? That might change their relationship with pain and death and, eventually, make that individual capable of acting.
In the above scenario, emotion dysregulation facilitated suicidal desire, but it was chronic non-suicidal self-injury that facilitated the capability for suicide and prompted the transition from ideation to action.
Why is that important to consider? When we're making decisions about imminent risk with a client and trying to determine the best available intervention, we are best able to do so when we have a clearer sense of where they are on the ideation to action continuum. We'll likely never be perfect, but by asking the right questions, we can up our odds of providing optimal care.
I could go on about this for a LOOOOONG time, but I don't think anyone wants to read that much, so let me wrap this up by returning to what prompted this post. The individual who wanted to de-emphasize means restriction to focus on depression, in my opinion, was missing the point because his focus is on a variable that - while important - really only strongly predicts an individual landing in the larger suicidal ideation group rather than a variable that might facilitate shifting from ideation to action. Klonsky in his new Three-Step Theory of suicide risk argues that access to and familiarity with lethal means (e.g., guns) is actually a component of suicidal capability. Given our recent work on the impact of state laws regulating handgun ownership and statewide suicide rates, I think he makes a strong point there. If we go along with that idea, then by restricting access to those means, we are diminishing capability for suicide and, remember, in the absence of capability, suicidal desire is highly unlikely to transition into action. Now, don't get me wrong, I'm not saying we should not treat the depression. Of course we should, but as one component of risk prevention. An individual receiving behavioral activation for depression is still an individual who could benefit greatly from diminished capability for suicide.