Scientists have dedicated a tremendous amount of effort and resources toward understanding potential risk and protective factors for self-injurious thoughts and behaviors (SITB). Some have proposed that cognitive flexibility is protective factor against SITB (Bryan, 2019; Rudd, 2007), and others suggest that this process can increase risk for suicidal behaviors under certain contexts (Nangle et al., 2006; Park & Ammerman, 2023). Several interventions for SITB include strategies to improve cognitive flexibility (e.g., Bryan, 2019; Kiosses et al., 2018; Linehan, 2015). However, the scientific literature on cognitive flexibility in SITB is filled with conflicting findings. Researchers also vary widely in their definitions of cognitive flexibility and in which measures they select to assess this construct. Thus, it has proven difficult to evaluate how and/or when cognitive flexibility may influence SITB, and whether strategies targeting flexibility actually reduce risk.
What exactly is cognitive flexibility and how might it impact SITB?
Cognitive flexibility refers to a person’s ability to adjust their goals, their perspective, and/or their approach to meet both internal and external demands required by a given task (Diamond, 2013). This process is critical for effective problem-solving, planning, reasoning, and for overriding habitual or automated responses. A person experiencing difficulties in this domain (i.e., cognitive inflexibility) may use the same strategy again and again to approach a problem, even when that strategy is ineffective or harmful. Similarly, they may have trouble generating alternative ways to see a given situation, or in shifting their priorities to meet new or changing demands. Many researchers have theorized that cognitive inflexibility may increase risk for SITB, since problem-solving may be impaired, and persons may find themselves stuck feeling hopeless and emotionally distressed. On the other hand, greater cognitive flexibility may increase risk for suicidal behaviors in certain contexts and for some populations. For example, the ability and willingness to use different self-harm methods increases risk of suicide. Being able to generate multiple ways to overcome barriers to suicide would also increase risk for serious injury or death.
To measure cognitive flexibility, scientists have employed a wide range of behavioral tasks and self-report measures. For example, participants may need to adjust to different sets of rules for a given task or alternate between rules (e.g., connect circles in ascending order, alternating between circled letters and numbers). The more a person fails to adjust to a new set of rules and continues to follow the old (now incorrect) set of rules, the greater their cognitive inflexibility. Scientists have also asked participants to report on their own tendency to reappraise a negative situation when trying to reduce negative emotions. Others have instructed participants to actively reappraise during a laboratory task where they can be observed. Some tasks assess a person’s ability to generate as many unique responses as possible that follow a given goal or rule (e.g., list as many unique words that start with the letter “s,” or generate reasons for why others may disagree with you in a hypothetical dilemma).
What do research studies say about cognitive flexibility and SITB?
We conducted a systematic review to synthesize the literature on cognitive flexibility and SITB and found 126 peer-reviewed studies. Although studies varied to some extent in terms of their findings, cognitive flexibility did not appear to be consistently or strongly associated with a history of SITB when researchers accounted for other mental health problems like depression. Some evidence indicates that the association between cognitive flexibility may be state-dependent. For example, difficulties in shifting approaches to meet a goal were associated with worse state (rather than a past history of) self-injurious thoughts. There is also some evidence that higher cognitive flexibility may have an indirect protective effect on SITB via buffering effects of stress and psychological pain.
Some studies indicated that certain cognitive flexibility strategies (e.g., reappraising a situation to reduce its emotional impact) may be more effortful and less effective for people with self-injurious urges. Similarly, some found that greater cognitive flexibility was positively associated with self-injurious thoughts for certain groups (e.g., boys with adjustment disorders). For example, when suicide is reframed to lead to positive outcomes (e.g., “everything will be better when I die”), some may experience suicide ideation with greater severity. Therefore, it is important to assess the target of cognitive flexibility (e.g., what and how is something being reappraised).
Although our review sheds light on the role of cognitive flexibility in SITB, our findings should be interpreted with caution. Many of the tasks scientists have used to measure cognitive flexibility may not adequately capture conditions and/or processes relevant to SITB. For example, a person’s ability to sort cards based on changing rules may not generalize to instances when they are deciding whether or not to self-harm. In our paper, we highlight several limitations of the present literature and provide recommendations to guide future research on cognitive flexibility and SITB.
Chung, J. J., Heakes, M., & Kaufman, E. A. (2023). The role of cognitive flexibility in self-injurious thoughts and behaviors: A systematic review. Clinical Psychology: Science and Practice. Advance online publication. https://doi.org/10.1037/cps0000163
- What are some important contextual factors to assess when researching the link between cognitive flexibility and SITBs?
- How does age or developmental status influence the relation between cognitive flexibility and SITB?
- Are there specific facets of cognitive flexibility that may be more important for SITB than others (e.g., task switching, generative flexibility)?
- What kinds of tasks would help us better understand cognitive flexibility in the context of SITBs?
About the Authors
Jason J.Chung (M.Sc) is a Clinical Psychology Ph.D. student at Western University. His research focuses on identifying and targeting transdiagnostic processes in high-risk behaviours (i.e., self-injury, substance use, suicide, and eating pathology). He hopes to apply his research for the betterment of minoritized and stigmatized groups (e.g., racialized groups, and sexual and gender minorities). Jason can be contacted at firstname.lastname@example.org and found on Twitter @JasonJChung1
Matthew Heakes (B.A., Hons) completed his Psychology undergraduate degree at the University of Guelph. His interests centre around fostering a better understanding of why people engage in behaviors that are harmful to themselves, with an emphasis on suicide and self-injury. He is particularly interested in exploring these behaviors using ecological momentary assessment. Matthew can be contacted at email@example.com.
Erin A. Kaufman (Ph.D.) is a clinical psychologist and faculty in the University of Utah’s department of psychiatry. Her program of research is focused on improving health outcomes for those vulnerable to self-inflicted injury (SII), borderline personality disorder (BPD), and suicide. At the broadest level, Dr. Kaufman studies prevention and intervention mechanisms for these populations, and strives to understand how social contexts interact with biologically-mediated regulatory processes to eventuate in SII and BPD. Dr. Kaufman can be reached at firstname.lastname@example.org or found on Twitter @Erin_A_Kaufman
Bryan, C. J. (2019). Cognitive behavioral therapy for suicide prevention (CBT-SP): Implications for meeting standard of care expectations with suicidal patients. Behavioral Sciences and the Law, 37(3), 247–258.
Diamond, A. (2013). Executive functions. Annual Review of Psychology, 64135–168.
Kiosses, D. N., Alexopoulos, G. S., Hajcak, G., Apfeldorf, W., Duberstein, P. R., Putrino, D., & Gross, J. J. (2018). Cognitive reappraisal intervention for suicide prevention (CRISP) for middle-aged and older adults hospitalized for suicidality. American Journal of Geriatric Psychiatry, 26(4), 494–503.
Linehan, M. M. (2015). DBT skills training manual (2nd ed.). Guilford Press.
Nangle, J. M., Clarke, S., Morris, D. W., Schwaiger, S., McGhee, K. A., Kenny, N., Murphy, K., Gill, M., Corvin, A., & Donohoe, G. (2006). Neurocognition and suicidal behaviour in an Irish population with major psychotic disorders. Schizophrenia Research, 85(1–3), 196–200.
Park, Y., & Ammerman, B. A. (2023). For Better or Worse?: The role of cognitive flexibility in the association between nonsuicidal self-injury and suicide attempt. Journal of Psychiatric Research, 158157–164.
Rudd, M. D. (2007). Fluid vulnerability theory: A cognitive approach to understanding the process of acute and chronic suicide risk. In T.E. Ellis (Ed). Cognition and suicide: Theory, research, and therapy. (pp. 355–368). American Psychological Association.