Month: October 2020

Hope

Posted on by erics

Hope is such a simple word. Yet for suicidal people in the depths of despair, hope is a beacon that they crave more than anything – but abjectly fear, because to believe in hope means to risk catastrophic disappointment. What I have come to learn over my decades in suicide prevention is that hope is everything to finding a way out of suicidal hell and into a life worth living with purpose and meaning.

There is a recent study of CAMS that I will be talking and writing about for years to come. For now, I will await publication of the investigation before saying more. But one of the key findings that most warmed my heart was how hope is engendered in suicidal patients engaged in CAMS.

Indeed, we know across clinical trials of CAMS that hopelessness is reliably decreased over the course of care while hope—and even optimism—is generated by the intervention as well. I know hope when I see it, and sparks of hope routinely occur at certain key moments across CAMS sessions. Within the first session of CAMS when the clinician and patient collaboratively complete the initial Suicide Status Form assessment there are often tiny sparks of hope. As the patient warily rates and describes elements of their struggle and the empathic clinician listens, validates, and actually gets what they are describing, there can be a glimmer of hope. When the clinician helps the patient elaborate the struggle and does not judge them, shame them, or ever wag a finger, there can be a flash of hope. When the clinician candidly speaks to the goal of keeping even a relatively highly suicidal person out of the hospital (if at all possible), there can be a spark of hope. So you are not going to try to get rid of me and lock me up?.

When the dyad carefully develops the CAMS Stabilization Plan for the patient and the clinician notes that the patient can learn to cope differently without resorting to suicide, there is often a curious look and sometime a twinkle of hope. Perhaps most dramatically, when the dyad completes the initial CAMS Treatment Plan in which the patient’s own suicidal “drivers” are identified (i.e., issues and problems that compel the patient to entertain suicide), goals and objectives are set, and potential interventions to target and treat those very drivers are noted, there is often an unmistakable flash of hope in the patients eyes. “Can you really treat these problems?” says an incredulous patient. In turn, the clinician replies, “…yes, of course we treat these problems all the time and if we do so successfully with you, perhaps you will come to see that you don’t need to end your life.” This is how CAMS-inspired hope may emerge in a first session.

My Suicide Prevention Lab (SPL) at Catholic University has been dedicated to many suicide prevention-oriented studies over many years. But one of the biggest tasks of the SPL my graduate students and I undertake is the fidelity and adherence work that we routinely do as part of clinical trials of CAMS. Fidelity is a solemn obligation within clinical trial research that requires that research investigators ensure that experimental and control treatments are indeed different from each other.

For example, within a CAMS randomized controlled trial (RCT) that means clinicians in the CAMS arm of the trial are doing the intervention adherently (as it was designed to be used) and clinicians in the control arm of the trial are not doing CAMS and are adherently providing the comparison treatment (e.g., usual treatment or Dialectical Behavior Therapy within our trials).

Here is the point: our job in these RCTs is to watch a lot of digital recordings of clinicians doing CAMS and often watching control sessions to ensure that the control treatment is being done properly. In other words, this fidelity work means we watch hundreds of hours of therapy sessions with suicidal people who are willing to participate in a RCT. It is from this perspective that my trained eye has come to recognize the behavioral, verbal, and emotional indicators of hope.

Hope is sometimes reflected in the almost shy glance that a patient makes towards the clinician—it is a look that says, are you for real? Can I trust you? Do you really mean it when you say you care about me? In later interim sessions of CAMS, hope is seen in a patient who sits up just a little straighter than they did in earlier sessions and who is genuinely interested in the clinician’s comments and input on their life and death struggle. Hope is seen in the flicker of smiles between patient and therapist as the dyad reviews “a good week.” Hope is often seen in an outcome-disposition session that formally draws CAMS to a close, wherein both parties reflect on how far they have come, appreciating and taking stock of gains made, and look forward to the road ahead in the patient’s “post-suicidal life.”

While the quantitative clinical trial results are robust, we know that decreasing hopelessness and increasing hope within CAMS is the lifeblood of a successful course of CAMS-guided care. Hope is simply the remedy to suicidal despair, desolation, despondency. And when you have seen the spark of hope in the eyes of suicidal person, you will never forget it. It is as if an entire inexorable fatal world view has been paused, gradually reconsidered, and even transformed into a world of potential possibilities.

In truth, hope does not happen every time with every patient. But within adherently provided CAMS we know that hope happens more often than not, and when hope happens truly anything is possible.

Such a simple word, hope, but in the suicide prevention and life-worth-living business it speaks volumes.

Considering Suicidal Ideation—Again!

Posted on by erics

In recent years I have spoken, published, and blogged about the relative importance of suicidal ideation as a public health concern that does not get the proper health concern of the public. A couple of other reminders came up just last week that again underscores the need to fundamentally shift our focus to appreciating the magnitude of the suicidal ideation population, which is 225 times greater than the population of those that die by suicide.

I was reviewing the most recent 2019 data from SAMHSA about the incidence of suicide-related concerns among American adults that calendar year. Take a close look at Figure 60 from the SAMHSA report—does anything particularly strike you?

Serious Thoughts of Suicide Graph

As I look at this figure my eyes are naturally drawn to the highlighted blue, green, and yellow regions that respectively reflect those who made suicide plans, those who made plans and attempted suicide, those who attempted suicide, and finally those who made no plans and attempted suicide (not sure how that works exactly but such are the data).

But upon some reflection, what jumps off the page to me is that the outer circle depicts 12,000,000 American adults with serious thoughts of suicide which is not highlighted, earning only a modest gray coloring. This SAMHSA report figure thus completely fails to highlight the true objective magnitude of our suicide ideation challenge!

My question is: Why is this population graphically trivialized in this figure? In truth, 12M Americans is a massive population, roughly the size of the state populations of Pennsylvania or Illinois. If we are truly examining the challenge of suicide as a public health issue, we of course care deeply about 48,000+ of Americans who died by suicide in 2018, and the 1.4M attempting suicide in 2019 is extremely concerning as well – but frankly these populations are utterly dwarfed by the massive suicide ideation population. And it logically follows that if we were better at identifying and treating this gigantic population, we may have many fewer attempts and ultimately many fewer completions. Right?

As I recently blogged, I have been honored to be a part of a small team that is working to write an addendum to the 2018 Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe promulgated by the National Alliance for Suicide Prevention. This draft addendum focuses on the apparent inclination of some health care systems to discontinue or suspend screening and assessment of suicidal risk since the Covid-19 pandemic which has driven our health care to online/telehealth modalities. In the forthcoming addendum there is a reassertion that even within telehealth there is a reasonable way to screen and assess for suicide risk (even if this is done asynchronously). In the addendum we have argued that not asking about suicide is no way to go about actually preventing suicides. After all, it is hard to save lives if we do not know that patients are at risk.

Here is the point: in my final review of the carefully written document our language tended to emphasize depression and suicidal behaviors, not even mentioning the importance of suicidal ideation. Even I, who have held these beliefs for some time, completely missed this omission in early drafts!

Mind you, depression and suicide are not synonymous; out of the 132 Americans that die from suicide each day in the U.S., roughly half may be clinically depressed (many others will be psychotic, anxious, substance abusing, personality disordered, etc.). In other words, depression is not even remotely the cause of many of our suicides since millions of Americans are clinically depressed and only a small fraction of them die by suicide.

In my final review of our addendum I made edits to de-emphasize depression and suicidal behaviors in lieu of emphasizing suicidal ideation, particularly as it relates to screening and assessment within a telehealth modality during a worldwide pandemic. I am pleased to note that while depression remains in the document, we have properly underscored the import of suicidal ideation and cited the SAMHSA paper noted above.

This is not going to be the last time that I appeal for us to recalibrate our suicide prevention policy, research, and clinical care focus to stop this peculiar bias to overly focusing on suicidal behaviors while dangerously disregarding suicidal ideation. My journal papers should not be rejected because CAMS “only” reduced suicidal ideation. Indeed, I would note within the clinical treatment research that other excellent suicide-focused interventions (e.g., DBT, CT-SP, and BCBT) do not reliably reduce suicidal ideation like CAMS does. However, these interventions more reliably reduce suicide attempts (while CAMS has only promising behavioral data thus far). The clinical trial data to date are exactly why I have strongly argued against a “one size does not fit all” approach to care for suicidal risk.

So, I am going to keep on banging the suicide ideation drum, appealing to those in our field to more completely consider the import and magnitude of the suicidal ideation population. In truth, if we truly aim to reduce completed suicides, our research, practices, and policies must better target and treat the underlying iceberg of suicidal ideation so as to reduce the tip above the water of suicide attempts and ultimately deaths by suicide.