The three-step theory of suicide: Description, evidence, and some useful points of clarification.

There has been considerable uptake of the Three-Step Theory (3ST) of suicide since its publication in 2015. The 3ST is a concise, evidence-based, and actionable theory that explains suicide in terms of four factors: pain, hopelessness, connection, and capability for suicide. The 3ST has not only been cited in hundreds of scientific papers, but incorporated into continuing education programs, gatekeeper training, and self-help resources. In this context, it is useful to clarify the theory's content and review its scientific support. Thus, the present article describes the 3ST, provides an updated evidence review for each of its premises, and offers several points of clarification so that the claims of the 3ST may be better understood, evaluated, and applied. To date, research (including research on correlates, risk factors, motivations, warning signs, and means-safety interventions) supports the 3ST. At the same time, there are aspects of the theory that are challenging to operationalize and that require further testing.

Clarifying the Relationship of Dissociative Experiences to Suicide Ideation and Attempts: A Multimethod Examination in Two Samples.

Fears of pain, injury, and death may represent key barriers to acting on suicidal thoughts. Dissociation, which involves a disconnection from one's body, may reduce fears and sensations of pain associated with harming the body, in turn facilitating suicide attempts. This study examined whether dissociation differentiated individuals with a history of suicide attempts from those with a history of suicide ideation, and investigated whether other relevant constructs explain this relationship. Sample 1 included 754 undergraduates (Mage = 21, 79% female) who completed a battery of self-report measures. Sample 2 included 247 undergraduates (Mage = 19, 74% female) who completed a self-report measure of dissociation, a clinical interview regarding suicide history, and four counterbalanced behavioral pain tolerance tasks. In both samples, dissociation was elevated in lifetime attempters compared to ideators (d = 0.28; d = 0.46; ps = 0.01) and slightly elevated in lifetime ideators compared to nonsuicidal individuals (d = 0.19, p = .02; d = 0.24, p = .47), though this effect was non-significant in the latter sample. In Sample 1, dissociation no longer differentiated attempters from ideators after controlling for clinical covariates. In Sample 2, dissociation was unrelated to behavioral pain tolerance tasks, and these tasks did not account for the association between dissociation and attempts. Overall, dissociation differentiated individuals with a history of suicide attempts from those with ideation alone in both samples. Pain tolerance did not explain this association; instead, it is possible that the relationship of dissociation to suicide attempts is due to "third variables" associated with both phenomena, such as symptoms of borderline personality disorder or posttraumatic stress disorder.

Examining suicidal desire through the lens of the three-step theory: A cross-sectional and longitudinal investigation in a community sample.

OBJECTIVE: Advancing evidence-based theories of suicide is critical to improving suicide prevention. The aim of the current study was to investigate suicidal desire through an emerging theory of suicide, the Three-Step Theory (3ST). Specifically, this study investigated the validity and predictive utility of Steps 1 and 2 of the 3ST in a Canadian community sample. METHOD: Participants were 487 adults between the ages of 35 to 90 (M = 59; 64% female, 87% White) who completed self-report measures assessing suicidal ideation and attempt history, hopelessness, psychological pain, and 5 forms of social connectedness at baseline and 6 months later. RESULTS: In support of 3ST predictions, cross-sectional analyses showed (a) the combination of pain and hopelessness strongly correlated with suicidal desire, and (b) connectedness was protective of suicidal desire among those high in pain and hopelessness. Regarding predictive utility, longitudinal analyses showed that pain and hopelessness were strong predictors of future suicidal desire and that connectedness was protective against future suicidal desire. These relationships of pain, hopelessness, and connectedness remained when controlling for baseline suicidal desire. CONCLUSIONS: Results support the validity and predictive utility of 3ST hypotheses related to suicidal desire. Taken together with previous studies, findings suggest that Steps 1 and 2 are useful for conceptualizing suicide risk and prevention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Motivations for suicide: Converging evidence from clinical and community samples.

Understanding what motivates suicidal behavior is critical to effective prevention and clinical intervention. The Inventory of Motivations for Suicide Attempts (IMSA) is a self-report measure developed to assess a wide variety of potential motivations for suicide. The purpose of this study is to examine the measure's psychometric and descriptive properties in two distinct populations: 1) adult psychiatric inpatients (n = 59) with recent suicide attempts (median of 3 days prior) and 2) community participants assessed online (n = 222) who had attempted suicide a median of 5 years earlier. Findings were very similar across both samples and consistent with initial research on the IMSA in outpatients and undergraduates who had attempted suicide. First, the individual IMSA scales demonstrated good internal reliability and were well represented by a two factor superordinate structure: 1) Internal Motivations and 2) Communication Motivations. Second, in both samples unbearable mental pain and hopelessness were the most common and strongly endorsed motivations, while interpersonal influence was the least endorsed. Finally, motivations were similar in men and women -- a pattern that previous work was not in a position to examine. Taken together with previous work, findings suggest that the nature, structure, and clinical correlates of suicide attempt motivations remain consistent across diverse individuals and situations. The IMSA may serve as a useful tool in both research and clinical contexts to quickly assess individual suicide attempt motivations.

A Brief Measure of Unbearable Psychache.

OBJECTIVE: Psychache has been proposed to cause suicide when it becomes unbearable. However, existing measures of psychache do not directly target unbearable psychache. Thus, the purpose of the current study was to provide initial validation for a brief measure of unbearable psychache. METHOD: Three items were selected to create the Unbearable Psychache Scale (UP3). Psychometric properties were assessed in two populations: (1) an online sample composed of 1,006 adults (53% male) from various locations in the United States and (2) a sample of 190 psychiatric inpatient adults (47% male) from a hospital in Western Canada. RESULTS: In both samples, the UP3 demonstrated excellent internal reliability, and strong convergent and predictive validity. Additionally, the UP3 predicted significant variance in suicidal ideation over and above documented correlates of suicidal ideation including general psychache, hopelessness, perceived burdensomeness, and low belongingness. CONCLUSIONS: The UP3 is a brief, psychometrically sound measure of unbearable psychache that may be well-suited for use in research protocols and clinical assessments.