Professor Regina Miranda My name is Regina  Miranda. I’m a Professor of Psychology at   Hunter College, of the City University of New  York, and my research seeks to understand why   young people think about suicide and  whether the form and the content of   their suicidal thinking might inform us  about their risk of making future suicide   attempts. [Pause] Suicide ideation involves having  thoughts about ending one’s life and these   can be thoughts that are more passive,  such as wishing that oneself were dead,   or more active suicidal thoughts, which involves  actually wanting to kill oneself and thinking   about methods that might – one might use to kill  oneself. This differs from suicide attempts,   which are – involve intentional self-injury  with the intent to die. So, meaning when a   person engages in self-injurious  behaviour with the intent to die. [Pause] There are a number of popular contemporary  psychological theories of suicide. This includes   the Integrated Motivational-Volitional Model of  suicide, the Interpersonal Theory of Suicide,   the Three-Step Theory of Suicide, the  Cultural Model of Suicide and others.   And these theories tend to address factors that  lead people to think about suicide and also,   that lead people to transition from thinking  about suicide to attempting suicide. And they   actually don’t tend to address, as much, suicide  ideation itself. So, what do young people actually   think about when they think about suicide and  what – kind of, how do they think about it? And so, two models that do that to some degree  are the Cognitive Theory of Suicide – Wenzel and   Beck’s Cognitive Theory of Suicide, and Rudd’s  Fluid Vulnerability Theory of Suicide. Rudd’s   Fluid Vulnerability Theory of Suicide draws  upon Aaron Beck’s theory of suicidal modes,   meaning interconnected networks of thoughts,  feelings, behaviours and motivation related   to suicide, that are triggered when somebody  thinks about or attempts suicide. And the idea   is that the more one thinks about or makes  a suicide attempt, the less it may take them   to think about or attempt suicide in the future.  Because the more that suicidal mode is triggered,   the lower the threshold for triggering  a future suicidal episode. So that now,   it takes less for a person to start  thinking about or to attempt suicide.   And so, this model distinguishes between more  chronic suicide risk and acute suicide risk,   which tends to be impacted by more acute  factors, like negative life events that happen. Similarly, the Cognitive Model of Suicide suggests  that when – that people can have suicide related   schema. So, a schema is a mental representation  that helps us organise and process information.   And when a suicide related schema is activated,  people experience hopelessness about the future   and that leads them to narrow their focus to  suicide related information or stimuli. Meaning   that they start thinking about suicide and may  have difficulty because of its narrowed attention   to suicide-related information disengaging  their attention from suicidal thoughts. And to the degree that they have diff – that  difficulty disengaging attention from suicide   related information, when they reach a certain  threshold of distress or tolerance for the   distress that they are experiencing, they’re  more likely to transition from thinking about   suicide to attempting suicide. So, that idea  of this biased attention to suicide related   information as a more chronically activated  suicidal related schema or suicidal mode,   is what – part of what informs some of  the work that we’ve been doing trying   to understand different profiles  of adolescent suicide ideation. [Pause] It’s important to understand why  adolescents think about suicide, because that   can not only inform future risks of attempting  suicide, but it can also inform how we intervene   to address suicide ideations. Often, we assess  whether suicide ideation is present, whether it’s   active or passive and characteristics like ‘wish  to die’, but there has been relatively little work   on understanding specific features of suicide  ideation that might be informative about risk   of leading to suicide attempt. So, there might  be some teenagers who think about suicide very   rarely, who think about it once in a while, and  those teenagers might be different from teenagers   who think about suicide more persistently. And  that might have implications for how interventions   are designed to address their suicidal ideations. In addition, oftentimes, when we train Clinicians   to perform risk assessments, or when we learn  to do risk assessments ourselves, there tends   to be this fear based – there’s a – tends to be a  fear that gets activated in a Clinician when they   hear that someone is thinking about suicide. And  that may be partly due to lack of familiarity with   suicide ideation and really try to understand  suicide ideation and engaging with teenager’s   suicidal thoughts to better understand them.  I think that the more that we can engage with   those thoughts and understand those thoughts, the  less we’ll be afraid when somebody tells us that   they’re thinking about suicide. Because we’ll be  able to better understand more about their risk   profile, but also about the suffering that is  leading them to think about killing themselves. [Pause] One of the fact – study cognitive factors  that is – has been found to be a correlate and   a predictor of suicide ideation is hopelessness.  Meaning a tendency to expect that bad things will   happen in one’s future, that good things won’t  happen in one’s future and that no matter what,   one is helpless to stop those things from  happening. They’re not happening. So,   it has to do with expectations  about the future and we know   that those are associated with suicide  ideation and suicide attempts. And so,   what some of our work has sought to do is to  try to better understand and tease apart the   various components of hopelessness that might  be involved in suicide ideation that – or that   might precipitate suicide ideation. And we  focused on understanding the differences   between hopelessness involving expecting  negative things to happen in one’s future,   versus hopelessness that involves expecting  an absence of positive future expectations. And what some of our past research  has suggested, and that of others,   is that one unique component of hopelessness  that may predict suicidal thinking independently   of depression is a tendency to expect that  good things won’t happen in one’s future. So,   a lack of desired future outcomes. And we’ve  also tried to understand how different forms   of repetitive thinking might lead to those  hopelessness related cognitions or thoughts.   And we’ve studied that in relationship  to the self-focused rumination or mood   focused rumination, drawing on the work  of Susan Nolen-Hoeksema and others,   and specifically try to distinguish between  brooding rumination, which was defined by   Nolen-Hoeksema and others as “a tendency to  dwell on one’s negative moods and constantly   feeling the consequences,” versus reflection,  which had been thought to be a more adaptive form   of rumination that involves trying to better  understand the reasons for one’s negative mood. And so, past research had found that  brooding, the brooding form of rumination,   was associated with increases in  depressive symptoms over a time,   whereas reflective rumination is associated  with decreases in depressive symptoms over   time. And in a paper that our lab published  with Dr Nolen-Hoeksema on 2007, we found,   for the first time, I believe, that both brooding  and reflection were associated with increases in   suicide ideation over time. And so, some of our  research has, since then, tried to understand   the circumstances under which reflection, which is  thought to be a more adaptive form of rumination,   might also lead to increases in suicide ideation  over time. And so, that is one form of repet –   maladaptive repetitive thinking that we’ve  studied in relation to suicide ideation. Another form of repetitive thinking that we’ve  been focused on is future-oriented repetitive   thinking, or future-oriented rumination. So, the  tendency to spend time considering whether bad   outcomes will happen in one’s future or whether  good outcomes will not happen in one’s future.   And in a paper that we recently published, we  found that pessimistic future-oriented repetitive   thinking, so the tendency to consider, repeatedly,  that bad things would happen or that good things   won’t happen in one’s future was associated with  increases in suicide ideation over time among   young adults and that that might be explained  by increases in hopelessness related cognition. So, it’s the more one spends time in that mental  rehearsal of pessimistic future expectation,   the more fluently those types of thoughts,  or those types of expectations or predictions   about the future, are made. And that might,  ultimately, lead a person to believe that their   pessimistic future expectations are inevitable and  to become hopeless about the future, and to lead   to increases in depressive symptoms, which are  associated with increases in suicidal thoughts. [Pause] Well, research by Susan  Nolen-Hoeksema, Ed Watkins,   Mark Williams and others, has suggested  that rumination impacts problem-solving. So,   the more a person spends time thinking about  why they’re feeling badly and about the causes,   feelings and consequences of that negative mood,  and the more that may impact their ability to   recall instances in which they were able to  effectively solve problems. Because the more   they’re in their head, they’re more they’re –  the less they’re in the present moment. And so,   rumination may impact risk for suicide ideation  by decreasing a person’s problem-solving abilities   and specifically the ability to think about  or remember situations in the past where they   might have been able to effectively solve  problems. And this has been proposed by   Mark Williams and others to be due to overly  general autobiographical memory, which has   been found to be associated with ruminative  thinking or perceptive thinking [pause]. That’s an excellent question and that’s one that  we’ve been trying to study for the past decade or   so. We actually don’t have a definitive answer on  suicide ideation subtypes that might predict risk   of a suicide attempt in the future, but we do have  some clues, based on current research and based on   some research that we’re doing. Specifically,  we’ve been focused on trying to understand   suicide ideation or suicidal thoughts that are  precipitated by just freak events and that last   a shorter period of time and that happen once in  a while, not very often, versus suicide ideation   that is more persistent, that might happen  every day or that might happen intermittently. And so, some preliminary data that we’re currently  looking at suggests that suicidal thoughts that   are more persistent might increase an adolescent’s  risk of making a suicide attempt in the future,   but also, if they make a suicide attempt, of  making that attempt sooner. And we’ve been trying   to understand what some of the attention-based  mechanisms might be involved in that risk. So,   whether it’s difficulty disengaging  their attention or greater engagement   of attention to suicide related material, or  more difficulty disengaging their attention   from suicide related information or  thoughts. And trying to understand   whether those mechanisms might explain increased  risk of making a suicide attempt in the future. This work is very preliminary. We haven’t  published it yet. We’re currently – we   just completed a study on this topic and  we’re getting ready to publish those data.   And we’ve been engaged in trying to better  understand what distinguishes adolescents   who think about suicide very briefly from  those who think about it more intermittently   and more persistently. Not only including  phenomenology of those suicidal thoughts,   but also, their past history of suicidal  thoughts and behaviour. But we also have   data from studies with adults using ecological  momentary assessments, so the work of Evan   Kleiman and others, that had suggested that  suicide ideation that remains more elevated   and persistent over time is also associated with  increased risk of having a recent suicide attempt. [Pause] So, that’s also a question that we’re  engaged in trying to understand what factors   distinguish teenagers who think about suicide  or what features of their suicidal ideation   distinguishes from – who think about suicide  from those who go on to attempt suicide. And a   paper that we recently published suggests that  – this is with a hospital-based sample. So,   we recruited teenagers from hospitals  primarily in New York City and we   interviewed them in detail about their  suicidal ideation, including what they   were thinking about when they were thinking  about suicide, how long their thoughts lasted,   their – the degree to which they wanted to die  when they thought about killing themselves,   and the methods that they thought about  when they thought about killing themselves. And what we found was that teenagers who  presented with suicidal thoughts and – but   who’d had a past history of suicide attempts,  differed significantly from those who presented   with suicidal thinking, but did not have a past  history of a suicide attempt. And specifically,   they more often reported that when  they thought about killing themselves,   they thought about it in pictures.  They had suicide related imagery. Generally speaking, a substantial proportion  of all of the teenagers in our study, whether   they presented with suicidal thoughts or suicide  attempts, reported that when they thought about   killing themselves, they thought in pictures.  They had suicide related imagery. However,   those who had a past history of a suicide  attempt did so more often than those   who were thinking about suicide without  having previously made a suicide attempt. They also reported suicidal thinking that was of  a greater duration, and those who made a suicide   attempt, who had presented with a suicide attempt,  also reported a greater wish to die when they had   thought about killing themselves, and also tended  to think about methods such as a drug overdose or   ingestion, which is a more acceptable method, or  might’ve been a more acceptable method for them.