Ideation to action theories

By Nathan Risch, PhD student, Montpellier, France

In the last decade, ideation-to-action theories of suicide have been very popular among researchers. Those theories posit that suicidal ideation and attempt are two distinct processes.
Suicidal ideation would emerge from:
– Thwarted belongingness and perceived burdensomeness for the interpersonal theory of suicide (Van Orden et al., 2010) ,
– Humiliation, defeat, and entrapment for the integrated motivational-volitional (O’Connor, 2011) ,
– Psychological pain and hopelessness for the three-step theory (Klonsky & May, 2015).

When patients have suicidal ideation, only those who have the acquired capability of suicide and the practical capacity of suicide will attempt suicide. Acquired capability refers to fearlessness about death and higher physical pain tolerance (Van Orden et al., 2010).

Fearlessness about death facilitates suicide attempts, whereas higher pain tolerance allows one to endure pain during the suicidal act and not stop during this aversive action. Meta-analysis reported higher acquired capability in past suicidal attempters compared to non-attempters (Chu et al., 2017) .

Practical capacity refers to access to lethal means, knowledge and familiarity with suicide methods (Klonsky et al., 2021). For example, patients who have access to lethal means such as fire guns are at higher risk of death (Conner et al., 2019). Patients who know how to attempt properly are at risk of death such as doctors, veterinarians or military (Hawton, 2000; Tomasi et al., 2019; Anestis & Bryan, 2013). Patients who practice non-suicidal self-injury have a familiarity with lethal means and could be prone to use lethal means. To date, reducing access to lethal means is one of the best way to prevent suicide (Mann et al., 2005) .


Anestis, M. D., & Bryan, C. J. (2013). Means and capacity for suicidal behavior: A
comparison of the ratio of suicide attempts and deaths by suicide in the US military and
general population. Journal of Affective Disorders, 148(1), 42–47.

Chu, C., Buchman-Schmitt, J. M., Stanley, I. H., Hom, M. A., Tucker, R. P., Hagan, C. R.,
Rogers, M. L., Podlogar, M. C., Chiurliza, B., Ringer, F. B., Michaels, M. S., Patros, C. H.
G., & Joiner, T. E. (2017). The interpersonal theory of suicide: A systematic review and meta-
analysis of a decade of cross-national research. Psychological Bulletin, 143(12), 1313–1345.

Conner, A., Azrael, D., & Miller, M. (2019). Suicide Case-Fatality Rates in the United States,
2007 to 2014: A Nationwide Population-Based Study. Annals of Internal Medicine, 171(12), 885

Hawton, K. (2000). Doctors who kill themselves: A study of the methods used for suicide. QJM, 93(6), 351–357.

Klonsky, E. D., & May, A. M. (2015). The Three-Step Theory (3ST): A New Theory of
Suicide Rooted in the “Ideation-to-Action” Framework. International Journal of Cognitive
Therapy, 8(2), 114–129.

Klonsky, E. D., Pachkowski, M. C., Shahnaz, A., & May, A. M. (2021). The three-step theory
of suicide: Description, evidence, and some useful points of clarification. Preventive
Medicine, 152, 106549.

Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A., Hegerl, U.,
Lonnqvist, J., Malone, K., Marusic, A., Mehlum, L., Patton, G., Phillips, M., Rutz, W.,
Rihmer, Z., Schmidtke, A., Shaffer, D., Silverman, M., Takahashi, Y., … Hendin, H. (2005).
Suicide Prevention Strategies: A Systematic Review. JAMA, 294(16), 2064.

O’Connor, R. C. (2011). The Integrated Motivational-Volitional Model of Suicidal Behavior.
Crisis, 32(6), 295–298.

Tomasi, S. E., Fechter-Leggett, E. D., Edwards, N. T., Reddish, A. D., Crosby, A. E., & Nett,
R. J. (2019). Suicide among veterinarians in the United States from 1979 through 2015.
Journal of the American Veterinary Medical Association, 254(1), 104–112.

Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner,
T. E. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575–600.

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