International Journal of Cognitive Therapy, 8(2), 114–129, 2015
© 2015 International Association for Cognitive Psychotherapy
114
Address correspondence to E. David Klonsky, University of British Columbia, Department of Psychology,
2136 West Mall, Vancouver, BC V6T 1Z4, Canada; E-mail: EDKlonsky@gmail.com
THEORY OF SUICIDE
KLONSKY AND MAY
The Three-Step Theory (3ST): A
New Theory of Suicide Rooted in
the “Ideation-to-Action” Framework
E. David Klonsky and Alexis M. May
Department of Psychology, University of British Columbia
Klonsky and May (2014) argued that an “ideation-to-action” framework should
guide suicide theory, research, and prevention. From this perspective, (a) the de-
velopment of suicide ideation and (b) the progression from ideation to suicide
attempts are distinct processes with distinct explanations. The present article in-
troduces a specific theory of suicide rooted in the ideation-to-action framework:
the Three-Step Theory (3ST). First, the theory hypothesizes that suicide ideation
results from the combination of pain (usually psychological pain) and hopelessness.
Second, among those experiencing both pain and hopelessness, connectedness is a
key protective factor against escalating ideation. Third, the theory views the pro-
gression from ideation to attempts as facilitated by dispositional, acquired, and
practical contributors to the capacity to attempt suicide. To examine the theory, the
authors administered self-report measures to 910 U.S. adults utilizing Amazon’s
Mechanical Turk (oversampling for ideation and attempt histories). Results sup-
ported the theory’s central tenets. First, an interactive model of pain and hopeless-
ness accounted for substantial variance in suicide ideation. This result replicated
in both men and women, and across age groups (i.e., 18–25, 26–35, and 36–70).
Also as predicted, connectedness was most protective against ideation in those high
on both pain and hopelessness. Finally, dispositional, acquired, and practical aspects
of suicide capacity each predicted suicide attempt history over and above current
and lifetime suicidal ideation. These initial findings support the 3ST. Implications
for suicide prevention and future research are discussed.
Keywords: hopelessness, ideation, pain, suicide
Suicide is a leading cause of death worldwide, killing more than 800,000 people
each year (World Health Organization [WHO], 2014a). A much larger number
of people make suicide attempts, with some researchers estimating that approxi-
mately 25 attempts occur for every suicide death (Goldsmith, Pellmar, Kleinman,
& Bunney, 2002). An even greater number of people consider suicide; a world-
THEORY OF SUICIDE 115
wide study found that for every person who attempts suicide, there are two to
three who have seriously considered suicide without attempting it (Nock et al.,
2008). Given this immense public health problem, suicide has been the focus of
many research and prevention efforts, particularly in the past few decades. Howev-
er, despite these efforts, there is no evidence of sustained reductions in suicide rates
(WHO, 2014b). The development of more effective prevention and intervention
strategies will very likely require a deeper understanding of the fundamental pro-
cesses that cause suicide ideation, attempts, and deaths.
TRADITIONAL THEORIES OF SUICIDE
Many theorists have sought to explain suicide. For example, Shneidman (1985,
1993) explained suicide as a response to overwhelming pain (i.e., psychache),
Durkheim (1897/1951) emphasized the role of social isolation, Baumeister
(1990) described suicide as an escape from an aversive state of mind, and Beck
and Abramson (Abramson et al., 2000; Beck, 1967) highlighted the role of hope-
lessness. These theories have been tremendously useful in guiding suicide research
and prevention efforts. At the same time, these theories share a particular feature
that may be limiting progress in understanding suicide: They fail to differenti-
ate explanations for suicidal thoughts and suicidal behavior. This distinction is
especially important when one considers that most people who develop suicidal
ideation never go on to make a suicide attempt (Klonsky & May, 2014; Nock et
al., 2008).
A NEW GENERATION OF THEORIES OF SUICIDE
A critical advance in suicide theory occurred 10 years ago when Thomas Joiner
(2005) introduced his Interpersonal Theory of Suicide. Joiner introduced a frame-
work by which (a) suicidal ideation and (b) the progression from ideation to
attempts were treated as separate processes that come with separate sets of expla-
nations and risk factors. Joiner proposed a specific application of the framework:
Perceptions of low belongingness and high burdensomeness combine to bring
about desire for suicide, whereas high capability for suicide facilitates potentially
lethal suicide attempts. However, we believe that the framework itself is at least
as important a contribution to the field as the particulars of his theory. Inspired
by Joiner’s work, we recently proposed that an “ideation-to-action” framework
should guide all suicide theory and research (Klonsky & May, 2014). That is, the
(a) development of suicide ideation and (b) progression from ideation to suicide
attempts should be viewed as distinct processes with distinct explanations.
We view Joiner’s Interpersonal Theory as the first ideation-to-action theory
of suicide, which has likely spawned a new generation of suicide theories. For
example, another recent theory of suicide, Rory O’Connor’s (2011) Integrated
Motivational-Volitional model, also proposes separate explanations for suicidal
116 KLONSKY AND MAY
ideation and suicide attempts. O’Connor suggests that defeat and entrapment are
the primary drivers of suicidal ideation, and that acquired capability along with
others factors (e.g., access to lethal means, planning, impulsivity) explain the pro-
pensity to act on suicidal thoughts. We find it extremely encouraging that theorists
appear to be embracing and utilizing an ideation-to-action framework.
OUR PROPOSED THEORY OF SUICIDE
The purpose of the present article is to describe and empirically evaluate our own
theory of suicide positioned within an ideation-to-action framework. Like the the-
ories of Joiner and O’Connor, our theory offers separate explanations for (a) the
development of suicidal ideation and (b) the progression from suicidal ideation
to attempts. The theory is relatively parsimonious in that suicide ideation and at-
tempts are explained in terms of just four factors: pain, hopelessness, connected-
ness, and suicide capacity. The theory is illustrated in Figure 1 and explained here.
STEP 1: DEVELOPMENT OF SUICIDAL IDEATION
Regarding the development of suicidal ideation, we believe that the first step to-
ward ideation begins with pain. Pain usually, but not necessarily, refers to psycho-
logical or emotional pain. Fundamentally, people are shaped by behavioral con-
ditioning. We perform behaviors that are rewarded and avoid behaviors that are
punished. If someone’s day-to-day experience of living is characterized by pain,
FIGURE 1. Illustration of our proposed Three-Step Theory (3ST) of suicide.
THEORY OF SUICIDE 117
this individual is essentially being punished for living, which may decrease the
desire to live and, in turn, initiate thoughts about suicide.
It is intentional that we do not specify the nature of the pain. Just as different
sources of punishment can similarly shape behavior (e.g., electric shock [Alexan-
der et al., 1973], loud noises [Watson & Rayner, 1920], noxious odors [Tanner
& Zeiler, 1975], social exclusion [Williams, Cheung, & Choi, 2000], or any suf-
ficiently aversive stimulus [Mazur, 2012]), we believe that different sources of
pain can all lead to a decreased desire to live. These may include physical suffering
(Ratcliffe, Enns, Belik, & Sareen, 2008), social isolation (Durkheim, 1897/1951),
burdensomeness and low belongingness (Joiner, 2005), defeat and entrapment
(O’Connor, 2011), negative self-perceptions (Baumeister, 1990), and myriad oth-
er aversive thoughts, emotions, sensations, and experiences. The first step toward
suicidal ideation begins with pain, regardless of its source.
However, pain alone is not sufficient to produce suicidal ideation. If someone
living in pain has hope that the situation can improve, the individual likely will
focus on obtaining a future with diminished pain rather than on the possibility of
ending his or her life. For this reason, hopelessness is also required for the devel-
opment of suicidal ideation. From our perspective, when someone’s day-to-day
experience is characterized by pain, and the person feels hopeless that the pain will
improve, he or she will consider suicide. In short, the combination of pain and
hopelessness is what causes suicide ideation to develop. Our perspective is con-
sistent with recent research finding that pain and hopelessness are the two most
common motivations for suicide attempts (May & Klonsky, 2013).
Importantly, we believe it is the combination of pain and hopelessness that is
required to bring about suicidal ideation. Someone in pain but with hope for a
better future will continue to engage with life. Similarly, someone who feels hope-
less about the future but without day-to-day pain will not consider suicide. The
latter situation may seem less intuitive than the former, so consider the following
example. A young adult recently graduated from university and moved back in
with her parents. If this young adult lacks a marketable degree, good grades, and
a sense of her career interests, she may very well feel hopeless about the future.
However, as long as her day-to-day experience remains comfortable with little or
no pain—for example, if her food and shelter are provided, she has free time to
spend with friends, and she enjoys participating in activities of her choosing—she
is unlikely to consider suicide. Pain and hopelessness in combination are required
for the development of suicidal ideation.
STEP 2: STRONG VERSUS MODERATE IDEATION
The second step toward potentially lethal suicidal behavior involves connected-
ness. Connectedness most often means connection to other people; however, we
use the term more broadly. Connectedness can also refer to one’s attachment to a
job, project, role, interest, or any sense of perceived purpose or meaning that keeps
one invested in living. Connectedness matters, because even if someone feels pain
and hopelessness and considers suicide, the suicidal ideation will remain moder-
118 KLONSKY AND MAY
ate (e.g., “sometimes I think I might be better off dead”) rather than strong (e.g.,
“I would kill myself if I had the chance”) as long as one’s connectedness to life is
greater than one’s pain. Consider the example of a parent who experiences daily
pain and hopelessness, but is invested in or connected to his or her children. If the
parent’s connectedness is greater than the parent’s pain, this individual may still
have passive ideation but will not progress to active desire for suicide. However,
if both pain and hopelessness are present, and connectedness is absent or less than
the pain, the individual will have strong suicidal ideation and an active desire to
end his or her life.
Disrupted connectedness is similar to low belongingness and burdensome-
ness as described in Joiner’s Interpersonal Theory. We therefore want to highlight
a key difference between our theory and the Interpersonal Theory. In our theory,
the primary role of connectedness is to protect against strong suicidal ideation in
those at high risk due to pain and hopelessness. While we believe disrupted con-
nectedness can contribute directly to pain and hopelessness, we do not view it as
necessary for the development of pain or hopelessness, and thus the development
of suicidal ideation. We believe that many people with disrupted connectedness
do not have suicidal ideation, and that many people with suicidal ideation do not
experience disrupted connectedness.
To be clear, our emphasis on pain, hopelessness, and connectedness in ex-
plaining suicidal ideation is not meant to suggest that other traditional risk fac-
tors for suicide are irrelevant. Indeed, we believe that numerous disorders (e.g.,
depression), states of mind (e.g., self-criticism), personality traits (e.g., borderline
personality), temperaments/dispositions (e.g., negative emotionality), and experi-
ences (e.g., interpersonal loss) are highly relevant to suicidal ideation. However,
we believe that they are relevant in a specific way, through their effects on pain,
hopelessness, and/or connectedness. For example, we would expect depression to
relate to suicidal ideation to the extent that it influences pain, hopelessness, and/or
connectedness, but not beyond.
STEP 3: PROGRESSION FROM IDEATION TO ATTEMPTS
Once an individual has developed a desire to end his or her life, the next question
is whether the person will act on that desire and make an attempt. We agree with
Joiner (2005) that the key determinant is whether the individual has the capability
to make a suicide attempt. As Joiner argues, people are biologically and evolution-
arily wired to avoid pain, injury, and death. It is therefore very difficult for people
to attempt suicide, even in the presence of strong suicidal ideation. However, we
expand on Joiner’s notion of capability in two ways.
Joiner emphasizes acquired capability. Acquired capability refers to an indi-
vidual’s habituation to pain, fear, and death through exposure to life experiences
such as physical abuse, nonsuicidal self-injury, the suicide of a family member or
friend, combat training, or any other experience that subjects someone to painful
and provocative events. We take a broader perspective and propose three specific