5 - (IOP41) The Three Step Theory: A Transdiagnostic Theory of Suicide Grounded in Behavioral and Cognitive Principles

The Three-Step Theory (3ST) is a concise, evidence-based, and actionable theory of suicide. Of note, the 3ST is grounded in behavioral and cognitive principles, and explains suicide risk across, and even in the absence of, psychiatric diagnoses (Klonsky & May, 2015; Klonsky et al., 2021). There has been considerable uptake of the 3ST since its publication in 2015. The theory has been cited in thousands of scientific papers, and incorporated into continuing education programs, gatekeeper training, and self-help resources. The purpose of this presentation is to describe the 3ST, its theoretical rationale, its evidence base (spanning numerous countries, populations, and research designs), and its implications for clinical practice and suicide prevention.

Step 1 of the 3ST suggests that suicidal desire results from the combination of overwhelming pain and hopelessness. Though it is usually psychological pain that contributes to suicidal desire (Shneidman, 1993), pain of any form (e.g., relationship disruption, job loss, mental illness, medical conditions) can contribute in Step 1. As deeply behavioral creatures, humans are hard-wired to avoid pain and painful experiences. Thus, if one experiences life as painful, miserable, or aversive, they are being ‘punished’ for engaging with life, and will experience a powerful instinct to find a way out.

Importantly, overwhelming pain is not sufficient to produce suicidal desire. If pain is accompanied by hope that a situation can improve through time or effort, then the focus will be on reaching a better future. In contrast, if an individual experiencing intense pain is hopeless about their situation improving, they will begin to consider suicide as a way out. In short, the combination of intense pain and hopelessness causes suicidal desire.

Step 2 suggests that ideation becomes strong when pain exceeds or overwhelms connectedness. Connectedness — to loved ones, valued roles, or any sense of meaning or purpose — acts as a ‘reward’ for engaging in life and can make life worth living despite pain.

Step 3 suggests that strong ideation progresses to action when one has the capability to attempt suicide. The 3ST specifies dispositional, acquired, and practical contributors to suicide capability.

The 3ST is supported by evidence from multiple countries and different types of data, including: motivations for suicide, antecedents of suicide attempts and death, correlational studies and longitudinal studies (for review see Klonsky et al., 2021). Importantly, the 3ST suggests that any method of prevention or intervention – whether behavioral, cognitive, social, or pharmacological – will reduce suicide risk to the extent that it (a) decreases pain, (b) increases hope, (c) enhances connection, and/or (d) reduces capability. In addition, the 3ST suggests the field would benefit from an increased focus on prevention, and a reduced focus on prediction.