Author: erics

Clinician-Survivors: The Peril and Promise of Risking to Care

Posted on by erics

Losing someone to suicide

As a clinician and suicide treatment researcher, I have contemplated for decades the prospect of losing someone to suicide. I regularly think about risking to care for people who struggle with thoughts of suicide. Like so many, I have personally known several people who have died by suicide. There was a painful loss of a friend and faculty colleague, who was literally across the hall from me. Tom took his life in the midst of four of us in my department conducting suicide research. Losing Tom was heartbreaking; the eyes of our graduate students were fixed on us faculty as they wondered how could you all have missed this? How could you have let this happen? I have often reflected on the moment a few days before Tom died when he stopped by my open office door to say “hi” and have a quick chat—something we both did countless times over the years as office neighbors. But this particular time after a brief exchange, Tom lingered at my door for a couple of beats as I turned to my computer to respond to my emails. In hindsight, I wish I had taken his subtle cue to invite him into my office to talk in more depth which was something we regularly did. But alas I did not and three days later Tom ended his life. Could my talking to him have prevented Tom’s suicide? I tell myself no, but I nevertheless regret what I failed to do in that moment, given what came to pass. I miss Tom both as a friend and faculty colleague.

Patients who are seriously suicidal

When I was in graduate school I worked as a Psych-Tech on an inpatient psychiatric unit. Within this role I helped avert several suicide attempts (two of which were patients on “15-minute checks” in the middle of hanging themselves in their rooms). While no one died, two patients came within a hair’s breadth of taking their lives. Some years later toward the end of my clinical internship within a V.A. Hospital, I gave a Rorschach Inkblot Test to a veteran who was deeply depressed. This patient struggled with the testing and we feared a closed head injury prompting us to pursue neuropsychology testing. But this testing never occurred because a few days after I met him, this profoundly depressed patient (a father of three young kids) laid down in front a bus as it departed from the hospital bus stop crushing him to death. Did I miss this patient’s potential for suicide? Yes, I had no inkling that this patient would soon be dead. I had met with him for 40 minutes before stopping the Rorschach given his abject inability to do the test. Do I have regrets about missing his suicide risk? Yes of course, but I do not blame myself for missing it.

Losing patients to suicide

As a practicing clinical psychologist for over 35+ years I have likely worked with thousands of patients in the V.A., in university counseling centers, and then as a private practitioner right up to the present day. Over my career, I have seen and treated hundreds of patients who have been suicidal. And while I have cut back on my clinical practice, I still see a couple of patients who are periodically suicidal. Over these years, I have had a half dozen patients make suicide attempts, a few of which could have been fatal but for twists of fate. As I reflect on clinical practice, I have no illusion that I will not lose a patient to suicide just because I am an expert on the topic. When it comes to suicide, no provider is infallible. Indeed, two of my beloved mentors lost patients to suicide. The late Dr. Terry Maltsberger, known for his seminal work on suicide-related countertransference, worked at McLean Hospital and Harvard Medical School, and he maintained a vibrant private practice. Over his career Terry counted himself “lucky” for never losing a patient to suicide after decades of seeing countless patients whom were highly suicidal. But then Terry lost a private practice patient shortly before he retired. Over the years that Dr. Marsha Lineman developed DBT within randomized controlled trials (RCTs), she always saw high risk patients and lost several of her patients to suicide. Thus, even these giants of clinical suicidology were not immune to losing patients.

The need for evidence-based treatment

In more recent years as I have dialed back my clinical practice, I have expanded the clinical trial research of CAMS, resulting in 9 published open clinical trials, 5 published RCT’s, along with two independent meta-analyses that support the effectiveness of CAMS. Given the risk, it is perhaps not surprising that we have also lost 4 patients to suicide who were in CAMS clinical trials. A particularly painful reality for my graduate students and me is watching sessions (on a secure platform) to ensure that CAMS providers are adherent and that RCT fidelity is assured. But in watching these cases for research purposes, we get drawn in and care about the clinicians and their patients. In one particularly challenging case, a CAMS study patient received over 20 sessions only to take her life as she seemed to deteriorate on video before our eyes. This death occurred despite an adherent provider who heroically used CAMS with the best consultation we could provide. We were heartbroken by this patient’s suicide and a tearful grad student asked me, “…after all these years, how do you handle a suicide like this?” My answer: “While losing this patient breaks my heart, and sobers me, it does not deter me from doing what we are doing…and actually it compels me to work even harder…we are not going to not do this kind of research because of this tragedy…we have to remember that we have helped save many more lives than we have lost and that fact keeps me going so others do not have to die this way.”

Using CAMS can help clinical confidence and may comfort family

I have a colleague who attended two early trainings of CAMS and she routinely used it in her counseling center work. After much success using CAMS with counseling center clients, she saw a grad student in chemistry who had a serious history of suicide risk (including two inpatient stays). The provider engaged this client in CAMS for six sessions, but the patient used an “exit-bag” to take his life by inhaling helium. In the midst of her grief, the clinician reached out to me for consultation and together we reviewed de-identified copies of the client’s SSFs during a phone consultation. With the wisdom of hindsight, I noted a few observations for improvement, but overall I felt that the clinician did an excellent job and she was certainly adherent to model. During our call I shared my heartfelt support and gave her encouraging feedback as I expressed my sincere condolences. I reassured her that she had done right by this client. Some six months later, this clinician re-contacted me for a follow up consultation in which I learned that the client’s parents had come across a file folder in their son’s desk entitled “Therapy” with copies of his SSF’s from his CAMS sessions. In that same folder was a printout of internet information about obtaining and then using an exit bag for suicide. The clinician told me that she spoke to the mother, and later the father who joined the 2-hour phone call. Towards the end of the call the bereft mother asked the provider, “…and what can we do for you? Because of course you lost our son too…are you doing okay?” The father finally noted, “…at least we have the comfort of knowing that the counselor who saw our son did not have her head in the sand when it comes to suicide…thank you for what you tried to do for him.”

The risk to care is worth it

When working with suicide risk there are obviously perils and the potential for heartbreak which must be balanced with the promise and rewards of life-saving care. One does not come without the other. What keeps me going is a grim acceptance that no clinician is immune to losing a patient. But I do take comfort and draw strength to persevere in the knowledge that I am able of provide the best possible care that I know to render. What more could I ever aspire to do when faced with the perils of suicide? For me, the risk to care continues to be worth it, because it can literally mean the difference between a death and saving a life. And I find great inspiration in doing right by my patients and endeavoring to foster that same feeling in other providers so they too can provide the best possible care to help save lives.

Suicide Risk: Effective Clinical Assessment, Management, & Treatment

Posted on by erics

Major misunderstandings about clinical care related to suicidal risk tend to exasperate me a bit. Let me therefore address and clarify some common misunderstandings that can interfere with saving lives. The key constructs at hand are assessing suicidal risk, managing acute risk, and treating suicidal risk.

The Importance of Assessing Suicidal Risk

While it’s true that we cannot reliably predict future suicidal behaviors, assessing suicidal risk remains a crucial step in preventing suicide. The goal of suicide risk assessment is to identify individuals who may be at risk for suicide and develop a safety plan to prevent suicide.

It’s important to differentiate between screening and assessment. Suicide screening is a brief assessment of an individual’s risk for suicide, whereas suicide assessment involves a more comprehensive evaluation of an individual’s suicide risk. Both screening and assessment are important in identifying individuals at risk for suicide and ensuring they receive appropriate care.

Suicide Screening in Managing Suicidal Risk

Identifying individuals who may be at risk for suicide is crucial to save lives, and suicide screening is an effective approach to achieve this goal. Suicide screeners consist of a set of standardized questions or tools that are used to quickly identify individuals who may be at risk for suicide. The aim is to detect the prospect of suicidal risk using a short screener of questions.

ASQ and C-SSRS are two widely used suicide screeners with solid psychometrics, normed on both youth and adult populations. Developed by Dr. Lisa Horowitz at NIMH and Dr. Kelly Posner at Columbia University, respectively, these screeners are non-proprietary and available online. They have various versions for different populations and needs.

Although PHQ-9 is a free online screener, it was originally developed as a depression assessment and is therefore not a perfect screener for suicide risk. Suicide screeners such as ASQ and C-SSRS are preferred due to their psychometric robustness and suitability for suicide risk assessment.

Suicide Risk Screening vs. Suicide Assessment: Understanding the Difference

It is important to understand the difference between suicide risk screening and suicide assessment. Suicide risk screening involves the use of a standardized set of questions or tools to quickly identify individuals who may be at risk for suicide. In contrast, suicide assessment is a more in-depth process that involves the use of longer versions of suicide-specific assessment tools, along with clinical interviewing and relying on a clinician’s clinical judgement.

The C-SSRS is an example of a suicide-specific assessment tool that has longer versions for assessing suicide risk. However, there are many other proprietary assessment tools available that are not widely used. Research has shown that while clinicians prefer relying on their gut judgments, these assessments are never as good as actuarial assessment scales.

It is important to note that suicide risk screening and assessment are not the same as treatment. They are only the start of the process of identifying and addressing suicide risk. Clinicians should be aware of the different suicide screening and assessment tools available to provide the best care for their patients.

Managing Acute Suicidal Crises: The Importance of Intervention

IInterventions for managing acute suicidal crises are not a substitute for treatment or assessment. To help individuals in crisis, the Safety Plan Intervention (SPI) developed by Dr. Barbara Stanley and Dr. Greg Brown is widely used and proven to be more effective than the outdated “no-harm/no-suicide” contract. Another tool, the Crisis Response Plan (CRP) developed by Dr. David Rudd and studied by Dr. Craig Bryan, also shows promise in reducing suicidal ideation and suicide attempts. A recent meta-analysis of safety planning studies in Europe confirms that such interventions significantly reduce suicide attempts. However, it’s essential to note that managing an acute crisis is just the beginning and not equal to treating suicide risk.

Treating Suicidal Risk: DBT, CT-SP, BCBT & CAMS

Treating suicide risk is a critical aspect of suicide prevention. Several proven interventions have been developed and tested through randomized controlled trials (RCTs) by independent investigators. Dialectical Behavior Therapy (DBT) is effective in reducing suicide attempts and self-harm behaviors. Cognitive Therapy for Suicide Prevention (CT-SP) and Brief Cognitive Behavioral Therapy (BCBT) have both shown significant reductions in suicide attempts. However, these interventions are not necessarily effective in reducing suicidal thoughts. On the other hand, the Collaborative Assessment and Management of Suicidality (CAMS) is the most supported intervention for treating suicidal thoughts, with five published RCTs, nine published non-randomized clinical trials, and a new independent meta-analysis of nine CAMS trials. It is important to note that treating suicidal risk is not a one-size-fits-all approach, and treatment should be tailored to the individual’s specific needs.

* * * * *

In summary, some of my biggest professional frustrations around clinical misunderstandings related to suicide risk are implied above but permit me to spell them out plainly:

  1. Simply doing a suicide screening and/or an assessment is not an intervention.
  2. Having a patient complete a Safety Plan is not treatment.
  3. Many treatments used for suicidal risk have little to no empirical support (e.g., medications and inpatient hospitalizations).
  4. Not all suicide-focused treatments impact all aspects of suicidality (e.g., behaviors vs. ideation).

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The CAMS Approach: Effective Suicide Risk Assessment, Management, and Treatment

When it comes to suicide prevention, effective risk assessment, management, and treatment are critical. While the C-SSRS is an excellent screener and assessment tool for detecting suicide risk, it is not a treatment for suicidal risk. That’s where the Collaborative Assessment and Management of Suicidality (CAMS) approach comes in. CAMS is a proven, suicide-focused clinical intervention that includes both assessment and treatment components, with extensive empirical support.

One of the unique features of CAMS is its ability to function as a “therapeutic assessment” experience. It also manages and treats suicidal ideation better than any other clinical treatment available, with promising data on suicide attempts and self-harm as well. CAMS is not a one-size-fits-all solution, but it is an excellent option for the largest population in the field of suicide prevention: the 12 to 14 million Americans of all ages who experience serious thoughts of suicide.

Using CAMS can help clinicians avoid common clinical misunderstandings and ensure better clinical care, potentially leading to life-saving outcomes. So while the C-SSRS is a valuable tool for detecting suicide risk, it is important to remember that it is not a treatment. CAMS, on the other hand, is a proven approach that can effectively assess, manage, and treat suicidal risk.

Blog: CAMS Meta-Analysis: Intervention for Suicidal Ideation

Posted on by erics

By: Dr. Dave Jobes

I am delighted to blog about a brand-new meta-analysis of nine clinical trials showing robust support for the Collaborative Assessment and Management of Suicidality (CAMS). This landmark article has just been published in the suicide prevention field’s premier peer-reviewed scientific journal, Suicide and Life-Threatening Behavior.

The CAMS meta-analysis project was led by Dr. Joshua Swift, a well-established psychotherapy treatment researcher, and Associate Professor of clinical psychology at Idaho State University (ISU). Dr. Swift, along with two graduate students, pursued a rigorous meta-analysis of CAMS clinical trials during the summer of 2020, submitting their manuscript for peer-review in the fall. This meta-analysis was sponsored by CAMS-care, LLC with the goal of supporting an independent research laboratory to conduct a demanding and labor-intensive meta-analysis (which is a large study of various studies that meet certain specific selection criteria). It is noteworthy that Swift and his team are not suicide treatment researchers, which helped ensure a fresh and unbiased perspective to this rigorous scholarly undertaking.

To conduct this meta-analysis, the ISU research team identified over 1,000 published and unpublished articles, theses, and dissertations that referred to “CAMS” or “SSF” (the Suicide Status Form is a multipurpose assessment and treatment tool used within CAMS). Using certain selection criteria (e.g., empirical clinical trial data vs. conceptual; having a comparison control group design vs. no control comparison), the team eventually identified and selected nine9 clinical trials of CAMS comparing it to control treatments, such as “treatment as usual” (TAU) and one Danish trial comparing CAMS to Dialectical Behavior Therapy (DBT). Once the selected studies were identified, the team performed a series of statistical analyses across the studies to investigate the relative effect sizes related to clinical treatment outcomes (i.e., a measure of the relative impact of the interventions on certain key outcome variables). In other words, the overall impact of study treatments within and across all the selected clinical trials can all be compared within a meta-analysis (additional analyses related to “moderator effects” were also studied).

The results of their efforts were impressive. The research team found that, in comparison to control treatments, CAMS caused significant reductions in suicidal ideation and overall symptom distress while positively impacting hope/hopelessness and increasing treatment acceptability. There was non-significant—but trending—support for its positive impact on suicidal attempts, self-harm, and cost-effectiveness (but more data are needed to see if these effects could reach statistical significance). Importantly, in none of the nine selected clinical trials of CAMS was comparison treatment ever better than CAMS when overall “weighted averages” across studies for each clinical outcome were calculated. There were no significant differences between the use of CAMS with white vs. non-white patients (but more diverse clinical samples are needed; the European CAMS studies to date have primarily had patients who were Caucasian).

Interestingly, the clinical trials in which I (as the creator of CAMS) was directly involved did relatively worse than ones in which I was not involved! Thus, there is no “publication bias” or “allegiance effects,” which underscores the scientific objective nature of the meta-analysis evidence supporting CAMS. Dr. Swift’s team ultimately concluded that CAMS is “Well Supported” as a clinical intervention for suicidal ideation as per Center for Disease Control criteria (which is the highest level of empirical support).

Review the original article by Dr. Swift: The effectiveness of the Collaborative Assessment and Management of Suicidality (CAMS) compared to alternative treatment conditions: A meta-analysis

So, what does all this rigorous research of various clinical trials actually mean? In short, this meta-analysis of CAMS is a breakthrough investigation that caps off almost 30 years of hard-earned clinical trial research, which first focused on the early use of the SSF that later evolved into the suicide-focused clinical intervention that CAMS has become. This meta-analysis convincingly confirms that using this suicide-focused therapeutic framework works for many patients who are suicidal around the world and in different treatment settings (e.g., outpatient settings, crisis clinics, and inpatient settings). It confirms that emphasizing the four “pillars” of CAMS—collaboration, empathy, honesty, and being suicide-focused—is indeed a proven way of reliably decreasing suicidal ideation and reducing serious psychiatric distress.

One of my favorite findings from the meta-analysis is that the most robust weighted average was for the outcome of decreasing patients’ hopelessness while increasing their hope! This is an important finding about which I have previously blogged. For me, the publication of this independent and rigorous study is a career highlight and a convincing testament to the effectiveness of CAMS for patients who are suicidal around the world across a range of clinical settings. We can now say with confidence that CAMS effectively treats the most significant challenge that we face in the field of suicide prevention today: the massive population of people who struggle with serious thoughts of suicide. Given the evidence, we believe that CAMS can effectively treat the “iceberg” of people with suicidal thoughts, a population 225 times greater than the population of those who take their life (Reflections on Suicidal Ideation). If we succeed in our efforts to train more clinicians to provide “upstream” effective CAMS-guided care to those who struggle with serious suicidal thoughts, perhaps we can help divert such patients from going on to attempt suicide or even prevent them from suicide further “downstream.” Thus, the publication of this new meta-analysis supporting the use of CAMS by Swift and colleagues is a major breakthrough to realizing the ambitious goal of reducing suicide-related suffering in all its forms around the world.

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Background on the CAMS Framework

CAMS is a therapeutic framework for effectively treating suicidal risk. It evolved from a line of suicide risk assessment research that initially began at the University Counseling Center at The Catholic University of America in the late 1980s. The key tool in CAMS is the Suicide Status Form (SSF) which guides all clinical activity within the intervention—from the initial session, across all interim care, to the outcome/disposition session, which concludes the use of CAMS. The SSF, therefore, functions as a multipurpose assessment, treatment planning, tracking, to clinical outcome tool. Previous research has shown that the SSF serves as a “therapeutic assessment.” CAMS SSF-based treatment planning focuses on patient-identified suicidal “drivers,” which are the problems that compel them to consider suicide (e.g., a relational breakup or self-hate). CAMS, therefore, targets and treats the patient’s suicidal drivers over the course of care to achieve optimal clinical outcomes such as rapid reduction of suicidal thoughts (in as few as 6-8 sessions), decreased symptom distress, and decreased hopelessness with increased hope.

CAMS’s Purpose and Function

The purpose of CAMS is to engage a person who is suicidal in a strong therapeutic clinical alliance while increasing their motivation to be an active collaborator within their tailored suicide-focused care. CAMS thus functions as a guiding framework to help stabilize the patient’s life while suicidal drivers are addressed and treated throughout the course of care. CAMS concludes with a focus on purpose and meaning and the pursuit of a life worth living.

How Clinicians Utilize CAMS

Clinicians across a range of clinical settings use CAMS to effectively stabilize and treat patients who are suicidal. The framework is atheoretical, which means that it is not tied to a particular theoretical orientation or set of techniques. The SSF provides structure for assessing suicidal risk at the start of each session and ensures that the suicide-focused treatment plan is updated at the end of every CAMS-guided session. The SSF also helps create extensive medical record documentation that reflects effective suicide-focused assessment, treatment planning, and follow-through. This kind of documentation reflects good practice and helps decreased the risk of malpractice liability related to working with patients who are suicidal.

Why CAMS is Effective in Reducing Suicidal Ideation and Associated Issues

Research has clearly shown that when CAMS is used adherently, it reliably reduces suicidal ideation and overall symptom distress, while increasing hope, and improving retention to clinical care. While more research is needed to understand the exact mechanisms of CAMS, we believe that a strong clinical alliance along with empathy and validation are essential ingredients to all successful CAMS-guided care. Research also shows that CAMS seems to change the patient’s “relationship” to suicide, providing alternative coping methods and getting needs met. Beyond helping patients become less suicidal, CAMS also encourages patients towards the end of care to actively consider the pursuit of plans, goals, and hope for the future within a life worth living—a “post-suicidal” life—a life with purpose and meaning.

The Need for Effective Suicide Interventions

There are remarkably few proven-effective clinical treatments for patients who are suicidal. Many practitioners rely on inpatient hospitalizations and psychotropic medications which have limited to no evidence for being effective with suicidal risk. Other effective treatments like Dialectical Behavior Therapy (DBT) or suicide-specific Cognitive-Behavioral Therapy (CBT) are more effective with decreasing suicide attempts, whereas CAMS reliably treats the much larger population of people with serious suicidal thoughts. Moreover, CAMS is relatively easy to learn compared to DBT and CBT and is generally more flexible and adaptable to different settings and theoretical orientations compared to other effective suicide treatments.

The Merit of CAMS is Undeniable

CAMS is a proven and effective treatment that is relatively easy to learn and ensures good practice and documentation that helps decrease practitioner exposure to liability. Research has shown that patients significantly prefer CAMS to usual care, and training in CAMS has been shown to increase provider competence and confidence, which are critical to successful care.

Case Example

In a randomized controlled trial of CAMS conducted at a U.S. Army infantry post, there was a multiply deployed Soldier “John” who came into treatment after being referred by his commander. John had significant combat-related trauma, and he was extremely upset that his ex-wife was moving to another state taking their two young sons. His CAMS clinician—a skilled clinical social worker—engaged him with the SSF in the first CAMS session. They readily identified his suicidal drivers: combat-related PTSD and the potential loss of access to his sons.

Over the course of ongoing interim CAMS care, the clinician effectively treated the Soldier’s PTSD with cognitive processing therapy (CPT). The clinician also arranged for the Soldier to meet with a JAG officer to receive legal consultation related to gaining joint child custody. Beyond treating his drivers, a significant issue with this Soldier was the clear need for John to leave the Army because of his inability to engage in further combat deployments (given the PTSD from his four previous combat deployments). During interim CAMS sessions, the clinician was able to gently persuade John to consider a medical separation from the Army, and together they engaged a VA provider who could see John after separation. They also explored various job options he could pursue as a civilian. Within a few weeks, with legal help from JAG, John obtained joint custody of his children and secured an arrangement for parental visitations. By session 9 of CAMS, John no longer had suicidal thoughts. While he was sad to leave the Army, John was excited about some job opportunities and the prospect of getting an associate degree with his VA benefits. John’s suicidal ideation had significantly resolved in fairly short order, and his symptoms of PTSD and anxiety were notably reduced. John actually felt hopeful about his future and ultimately became eager to leave the Army for a promising life outside the military.

In John’s case, we see all the elements of what Swift et al. found within their landmark meta-analysis of nine CAMS clinical trials. At the conclusion of CAMS, John began to realize a post-suicidal life—one with promise and potential for having successfully completed a therapeutic course of CAMS-guided care. While there were no doubt challenges ahead, John found his way out of a suicide crisis that put his life in peril. After his treatment, John saw that there could be life beyond being a Soldier,; a life with purpose and meaning—a life worth living.

Lethal Means Safety and CAMS

Posted on by erics

It is interesting how ideas and constructs within suicide prevention that have been around for many years can rather suddenly become popular. For example, the notion of “lethal means safety” (LMS) has been around for as long as I have been in suicide prevention (which is now pushing 40 years).

We used to refer to LMS as “restricting access to lethal means,” but there was a sense that firearm owners might be sensitive to this language as a threat to their second amendment rights. And if there is one thing that is true in the world of suicide prevention, it is that words matter! The most striking example is “committing suicide,” which has now been banished within the field because of how it criminalizes the behavior (“die by suicide” is less stigmatizing). Indeed, recent LMS research has shown the referring to “firearms” is less off-putting to people who own them than the word “guns”—which is good to know! In any case, within contemporary legislation and policy, a particular emphasis on LMS has become red hot.

Understanding Lethal Means Safety

Simply stated, LMS broadly refers to any clinical, community-based, or policy-driven effort that literally blocks or hinders ready access to potentially lethal means that could be used in a suicide to end one’s life. The range of examples is extensive. In the United States, our #1 method choice is by firearm, and brilliant work has been done in recent years in this area by Mike Anestis at Rutgers, Kathy Barber and Matt Miller at Harvard, and Craig Bryan at Ohio State University. While it has been contentious, sincere efforts to engage the firearm community have led to some valuable shared perspectives that can be good for suicide prevention. But there are many other means, including hanging, jumping, drowning, helium “Exit Bags,” medications, razors/knives, carbon monoxide car exhaust, etc.

The Nuances of Lethal Means Interventions

Major population-level increases in suicides have been linked to certain lethal means. A decade ago, dramatic increases in female suicides in rural China were due to toxic pesticides. During the 1970s, Brits in the UK were using lethal coal gas fumes for suicides. These examples are well known because rather simple interventions that involved locking up pesticides and switching over to less toxic forms of coal directly reduced suicides in China and England, respectively.

Keith Hawton at Oxford did a clever study in the UK limiting daily access from pharmacies of over-the-counter pain-relievers and the use of blister packs that literally made it more difficult to gather a lethal dose (of the English equivalent to Tylenol) reduced overdose behaviors! My friend Konrad Michel in Switzerland has been the leader in the use of netting sites where people jump to their death.

During one family vacation, we visited a public park with Konrad at a palace in Bern where netting had been installed below a balcony of an infamous jumping location. Interestingly this net reduced suicide jumps to zero even though one can walk to the end of the balcony and jump off the side, but apparently, no one does this! So lethal means interventions do not have to be 100% foolproof; sometimes symbols of deterrence are quite effective.

Effective Lethal Means Safety Interventions

Within one early CAMS clinical trial, a patient lived in a group house where a loaded handgun was left on the dining room table for anyone that needed it! This was easily removed with the encouragement of the patient’s CAMS clinician. But then the patient had a prized knife collection and, when he became psychotic, he was tempted to stab himself in the eye (a rather gruesome method with uncertain lethality). He refused to surrender or give his beloved knives to another party for safekeeping.

Undeterred, the resourceful CAMS clinician bought him a metal box for his knives with a padlock and gave him the key. On top of his box was a taped copy of his CAMS Stabilization Plan. The patient was moved and grateful for this gift from his intrepid provider.

I once had a patient who almost jumped to her death but for a last-minute grab of her boyfriend (who I called to rescue her) as she started going over the railing. Following a two-week psychiatric hospitalization, we all agreed to have her life-saving boyfriend (who was a carpenter) build a wooden buttress to the sliding glass door to her balcony so she could not jump to her death.

Many of us who have seen suicidal patients over many years have countless stories of lethal means safety interventions that we have orchestrated that have made our patients immediately safer and less tempted by readily available lethal means. In my professional trainings, I often note that ready access to lethal means poses a “rival” approach to suicide-focused treatment for addressing the needs that underlie all potential suicides (e.g., unbearable suffering, isolation, financial ruin, etc.—what we call “drivers” within the CAMS Framework®). By removing temptation, the patient is more inclined to get needs met differently, more therapeutically, and the risk of suicide death decreased accordingly.

The CAMS Evidence-Based Approach to Lethal Means Safety

Within CAMS, lethal means safety is central to the evidence-based treatment framework. In fact, discussing access to lethal means is the first step in the CAMS Stabilization Plan. My friends Barbara Stanley and Greg Brown have developed the famous Safety Plan Intervention, which is a “first cousin” of the CAMS Stabilization Plan and Rudd and Bryan’s Crisis Response Plan. But in contrast to the CAMS Stabilization Plan, “Making the environment safe” is Step # 6 of the Safety Plan. The reason LMS is the first consideration of the CAMS Stabilization Plan is because of the differences between a one-shot Safety Plan Intervention and on-going treatment of suicidal risk, which is the emphasis in CAMS.

A common goal in “standard” CAMS is to keep a person who is suicidal out of the hospital if at all possible. In my view, the decision not to  hospitalize a patient in CAMS is almost always rooted in the quality of the Stabilization Plan we are able to negotiate with the patient. If there is strong push back about lethal means, we may have no choice but to hospitalize. But if I can persuade a patient to surrender a stash of pills to their partner for safekeeping or convince another patient to use a cable lock on their firearm for the duration of our treatment, the need to hospitalize is often eliminated. We can then proceed in good faith to complete the balance of the CAMS Stabilization Plan, which focuses on different problem-solving techniques, who to contact in crisis, identifying people who will help decrease interpersonal isolation, and addressing potential barriers to receiving CAMS-guided care. CAMS Treatment® planning then concludes with a discussion of patient-defined drivers and how we plan to target and treat those problems and issues over the course of using CAMS. LMS is thus central to the CAMS Framework.

Unconventional Care Saves Lives

Several years ago, I was in the lab watching a digital recording of a CAMS session for fidelity purposes in our Army randomized controlled trial of CAMS. One of my favorite therapists in the study was working with a challenging case of a Soldier who had been repeatedly sexually assaulted. In turn, she kept a handgun in a side table drawer next to her bed for protection. However, her method for suicide would be to use this very firearm. She was emphatic that removing the gun was simply not negotiable because of the rapes she had endured—a definite therapeutic standoff!

The clinician thoughtfully considered the potential clinical standoff for a moment and then proposed the following: make a box to store the gun and to put a picture of the Soldier’s niece on the box as a reminder about why she should fight to live (her niece was her #1 Reason for Living on the SSF assessment). The Soldier readily agreed. I was worried, but the clinician felt confident in his intervention. In her next CAMS session, the patient brought in a work of art: a beautiful wooden box that she made in a shop with decoupaged images of the beloved niece! In my consultation with the provider, I pushed to swap-out the firearm with a taser, but the patient had zero interest in my helpful LMS suggestion! This remarkable woman responded beautifully to CAMS in 8 sessions.

In any final successful course of CAMS-guided care, there is a question about “what made the difference?” on the final outcome-disposition SSF. This Soldier, without hesitation, said, “CAMS showed me I could get my needs met without resorting to suicide…and you let me keep my gun!”

The NEED for Competence and Confidence

Posted on by erics

I recently recorded a two-hour workshop on Zoom for a virtual presentation at the Psychotherapy Networker Symposium Conference that is held every year in Washington DC (in non-pandemic times). This conference is a major professional event for psychotherapists across disciplines and I was thrilled to be invited to do this workshop.

To my delight, the organizers proposed the following title: “Treating Suicide Risk with Competence and Confidence: How to Move Beyond our Fears.” I liked this title for many reasons but mostly because of the emphasis on competence and confidence which is critical for effectively working with patients who are suicidal.

I also loved the idea of “moving beyond fear” because for many practitioners, fear is what drives defensive practices and/or avoidance of patients who are suicidal. Clinical fears include fear of litigation should there be a bad outcome, fear of not being able to control the patient’s self-destructive behaviors, fear of investing in therapeutic care and concern for patient only to lose them to suicide. As I have previously blogged and written about many times, clinicians’ fear and avoidance of patients who are suicidal is a major barrier for patients receiving effective and potentially life-saving care.

Upon reflection the presentation turned out well, I think? One never knows talking at their laptop for two straight hours. In the virtual workshop I did my usual tour, beginning with the field’s historic mishandling of people who are mentally ill, which is frankly a pretty horrifying story of marginalizing persons who suffered, seeing them as deviants possessed by evil spirits. It is noteworthy that every major world religion has some form of ritual exorcism. Long before effective treatments took root, societies around the world largely responded to abnormal behavior through prayers, exorcism rituals, and crude interventions such as waterboarding and trephination (drilling large holes in the cranium to release evil spirits). Critically, people who were mentally ill were marginalized to the fringes of society as they were literally chained up in dank cellars, imprisoned in appalling jails, and ultimately sent to asylums.

There was a movement in the late 18th century led by Dr. Phillipe Pinel outside of Paris to liberate people who were mentally ill from their chains with the advent of so-called “moral treatment.” While philosophically compelling with some who aspired to make asylums a genuine kind of sanctuary (e.g., the 19th-century Kirkbride asylums in the United States) the reality of moral treatment was not reflected in the reality of “care” for those who struggled with mental disorders.

In fact, “lunatics” where warehoused, restrained, assaulted, and later in the 20th century given brutal treatments of electroconvulsive therapy (often breaking bones as patients convulsed) and the horrific use of “icepick” lobotomies. The latter was particularly crude and inexact—a Washington DC physician name Walter Freeman performed thousands of lobotomies, driving from hospital to hospital performing up to a dozen lobotomies per visit. He would take a sharp steel tool resembling an icepick that was hammered through the orbit of the patient’s eye through the cranium to sever—rather ineptly—portions of the frontal lobes. The procedure was initially celebrated as a wonder cure because patient behavior changed dramatically (despite patients dying and some receiving multiple “treatments”). Bottom line, not good.

Taken together it is a horrifying history that reflects a fundamental fear of mental illness and a societal desire to control abnormal behaviors by any means. Doctors largely sought to dominate, control, and restrict potentially undesirable behaviors—bizarre movements, violence, and of course suicide.

I take pains to share this sordid history because it is truly relevant to contemporary care. Certain patients—such as people who are suicidal—can evoke intense fear and be experienced as a threat, an adversary, and someone to be avoided. But in the clinical life-saving business it is extremely difficult to help save a life from suicide if the clinician is fundamentally afraid of their patient. And as I have noted in this blog there is a significant historic lineage of non-therapeutic fear.

The presentation then delved into my review of screening for suicidal risk, the use of assessment tools, and the relative limits—and problems—related to clinical judgement, not the least of which is the notable overconfidence that clinicians have in their “gut” judgement and their general aversion to assessment tools therein.

Next, I reviewed interventions that focus on the management of acute suicidal crises (e.g., safety planning, use of the National Lifeline and Textline, and lethal means safety). Having reviewed these topics, I then delved into the evidence-base of suicide-focused treatments (DBT, CT-SP, BCBT) which are supported by rigorous randomized controlled trials (RCTs) and the notable limits and lack of RCT support for medications in relation to suicidal risk. It follows that a good portion of the second hour focused on CAMS as a patient-centered, evidence-based, suicide-focused, clinical treatment supported by five published RCTs.

Here is the point. I do workshop talks all the time; I can expand, or contract the content, as needed depending on the forum and audience. But what really struck me about this Zoom-based workshop was that it targeted an audience that may feel fearful of suicidal risk,  which led to my sponsors’ proposed title. They expressly wanted me to address an audience of practitioners who need to move beyond fear to better help patients who struggle with suicidal thoughts.

Within this simple realization a few things struck me. I learned years ago in graduate school about the critical role that fear plays in our lives. Fear is limbic-based (the “older” part of our brain) and primitive. Fear is central to our “fight or flight” response that kept our ancestors alive. But fear also has the  power to paralyze—the proverbial deer in headlights. I also learned early on with a patient who was profoundly traumatized and diagnosed with dissociative identity disorder (i.e., multiple personality disorder).

Together we discovered a wonderful therapeutic “fairy tale” book about dissociation that noted the following key idea:  behind every fear is a legitimate need. Thus, if an ancient ancestor was chased by a  sabretooth tiger, it evoked tremendous fear and a clear need for safety from the predator so as to not be devoured. It follows, that in a contemporary sense, if we fear working with a person who is suicidal, there is a fundamental need for clinical competence (to do something that works) and confidence to work effectively with this inherently scary issue.

Fortunately, CAMS can offer a reliable path to clinical competence and confidence, which is the best way to deal with the clinical fear. Competence is rooted in doing something proven effective; with competence, confidence can follow. And here is the thing about confidence: it creates a placebo effect in the patient. If we can therefore be competent and confident, patients feel it and it changes their brain chemistry (as proven by placebologists who study the effect and changes that are seen in MRIs). And here is another thing about confidence: we know that training in CAMS significantly increases clinician confidence as per a rigorous study of trainings conducted by Dorian Lamis and his research team in Georgia (Associations of Suicide Prevention Trainings with Practices and Confidence among Clinicians at Community Mental Health Centers).

In summary, in the face of our fears about working with people who are suicidal, we can realize and embrace our need to practice with competence by using evidence-based approaches like CAMS. Moreover, we also know that training in CAMS significantly instills confidence in mental health providers, which changes brain chemistry and may play a critical role in in helping to clinically save lives.

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.

First Touch: Administrative Policy vs. Caring Concern, Empathy, Validation, and Truth

Posted on by erics

“I sure hope I can get her to come back so I can do CAMS with her. I think she would really benefit…but I’m afraid that she may have been scared off by our bio-psycho-social intake!”

This was said to me on a coaching call last week with a savvy Licensed Professional Counselor (LPC) I had previously trained, along with others who work with veterans and their dependents. This colleague was referring to the 19-year old dependent of a divorced veteran, who had been referred by her veteran father after she made a low-lethality overdose. The patient had just endured a 2-hour intake process required by agency policy, and this counselor was having trouble reaching her after her experience.

This account pains me greatly, and it is certainly not the first time I have encountered this problem – the effects of extremely long intake processes and administrative paperwork that most clinical settings require before any therapeutic care is provided to suicidal patients. I have been told by such agencies that “there are no exceptions.” So, even though a person is struggling with acute suicidal thoughts and/or behaviors, he or she must first endure hours of questions – some as inane as their birth order and whether they were delivered by forceps – before receiving any therapeutic assessment or suicide-specific treatment.

I believe there is often a unique moment, a window, of potential engagement that is squandered by unnecessarily long intake interviews and administrative paperwork. Administrative exceptions can and should be made for those who struggle with suicide. If we truly aim to clinically prevent suicides, the first touch experience for patients should be one of caring concern, empathy, validation, and truth – in other words, the CAMS assessment. I know this to be true because a published metanalysis proves that the CAMS assessment functions as a “therapeutic assessment” and further, we know from a randomized controlled trial (RCT) that suicidal patients prefer CAMS to usual care.

I face opposition to my position on the matter regularly. I win some, and I lose many. My first significant win occurred many years ago in a randomized controlled trial at a large VA Medical Center. In this instance, The Joint Commission’s “staff expert” was insisting on the first contact with the suicidal patient to be a 2-hour intake interview. The Chief of the service sided with me and agreed CAMS should be the first touch. I was thrilled to take the “win”.

However, at another large military medical center we were discussing how an abbreviated version of CAMS could be used in their emergency department, and the debate did not go my way. In this instance, not only was the provider arguing to initiate contact with a suicidal patient with an exhaustive intake procedure, but also stated “we could never engage on the topic of suicide so directly and quickly without forming a relationship first”, which he described as chatting about “the weather, sports, and the usual stuff”. I adamantly shared my opinion that such superficial chit-chat is ridiculous (it not only trivializes the seriousness of the patient’s suicidality, it is also transparently patronizing) and is no way to form a meaningful clinical relationship with a suicidal person.

As you might guess, I didn’t make many friends that day. Instead I was summarily dismissed, with the suggestion that I knew nothing about their military suicide patients and the challenges they faced. In truth, I have worked with suicidal military veterans for over 30 years, covering all four branches of the armed forces. I was appointed to a Veterans Blue-Ribbon panel by the Secretary of the VA, and to the Department of Defense Suicide Prevention Task Force. I was selected as a member of these investigative groups to become intimately knowledgeable of this “military suicide problem” in order to develop solutions. Finding the solutions was not the most difficult task – getting military mental health settings to implement them proved to be almost impossible.

The negative and vexing experiences these rigid and fruitless intake procedures cause simply must be reconciled with the reality of the challenges facing the suicidal person—and their provider—each time someone struggling seeks help that might avert a suicide outcome. The reality is that it is very scary for many to seek mental health care at all, let alone seeking care when one is contemplating ending their life by suicide. To be greeted by a stack of administrative documents and then subjected to an exhaustive “required” intake interview experience that may last up to two hours throws cold water on a patient’s motivation to seek care—it can be an instant turn off. Such requirements may close a window of opportunity to help save a person’s life through an evidence-based, suicide-focused treatment like CAMS. If we truly aim to clinically prevent suicides, the first touch experience for that patient should be one of caring concern, empathy, validation, and truth. Not data gathering and procedure-for-the-sake-of-procedure.

Our clinical experience and extensive research have shown that CAMS can be used to create a strong therapeutic relationship, forged in the crucible of the suicidal crisis. This is because CAMS providers go right into the patient’s suicidal struggle as they quickly engage with empathy, collaboration, and honesty using the Suicide Status Form.

I understand how people get comfortable with how things have always been done and fall into an “if it ain’t broke, don’t fix it” mentality. But what if it is broken? What if there is research evidence that proves it is broken, and by not fixing it many lives are lost? Shouldn’t we step out of this “comfort zone”? There are examples all around us of courageous people taking a stand to change policies that are wrong and harmful to individuals. It won’t be easy and it will be a long process, but those of us who believe in putting our patients first must fight for what the research is telling us and fix the currently broken mental health care system.

I will continue to beat this drum. In the meantime, for those mental health professionals who approach me with their challenges of how to effectively engage a suicidal patient when burdened with long intake interview requirements, I recommend that they not give up on the person. Follow up with the patient by phone or e-mail to get them to come back for a CAMS assessment and treatment. Additionally, when sending e-mail, include information about CAMS (Fact Sheet for CAMS Patients).  Besides working to change the system from within, it may be the best we can do for now. Lack of purposeful and caring follow-up may result in lost opportunities, and I fear possibly lost lives.

I do hope that 19-year-old patient comes back to give CAMS a try – it could make all the difference in her world and give her a second chance at life.

Jaspr: Using Avatars in Emergency Departments with Suicidal Patients Brings New Hope

Posted on by erics

It was a hot summer afternoon half a dozen years ago and I was talking to a couple of new colleagues, Dr. Linda Dimeff and Kelly Koerner, both of whom had trained under and worked with my research mentor Marsha Linehan (the famous developer of Dialectical Behavior Therapy–DBT). Linda was describing to me a fascinating study that was conducted at the University of Boston using a computer-based avatar of a medical-surgical discharge nurse (named “Nurse Louise”). The clinical trial study that we were discussing compared the impact of the Nurse Louise avatar to a living discharge nurse in terms of patient compliance with discharge orders. To my amazement the outcomes for the avatar “nurse” were far superior to the living nurse with significant reductions in recidivism (among other desirable outcomes).

Linda then asked me about the general experience of suicidal patients in emergency departments (EDs), which I knew to be uniformly negative (both as a clinician and from the relevant ED/suicide literature). Linda then proposed something outlandish: that we go for a NIMH Small Business Innovation Research (SBIR) grant to create an all new avatar-based intervention using a modified version of CAMS as the heart of the assessment and intervention.

Cams-care Image
“Dr. Dave” – the first avatar

Ultimately this initial conversation led to a “proof of concept” Phase I NIMH SBIR grant that supported the creation and preliminary investigation of “Dr. Dave”—a rather pedestrian avatar based on me! The patient will work through a CAMS-based Suicide Status Interview (SSI) assessment for suicidal ED patients while they wait, often for many hours, to see their ED doctor for evaluation and treatment disposition.

The Phase I study was a resounding success and we published an initial paper of our findings in a peer-review journal. The success of this proof of concept lead to a Phase II SBIR grant from NIMH to conduct a randomized controlled trial (RCT) of this new ED-based intervention.  I have come to truly love this line of research for many reasons.

Perhaps foremost in my mind, is that with some exceptions (for example, the inspired work by Dr. Ed Boudreaux), the ED has largely been completely ignored as a place to effectively work with suicidal risk. And yet every day around the world, suicidal people sit 6, 10, or 20 hours sometimes being “boarded” overnight waiting to see their ED doctor. For patients struggling with acute suicidal pain this ED wait is an intolerable eternity and it is not uncommon that patients simply give up and walk out the door.

Another amazing thing about this research has been the incredible engagement of people with lived experience (those individuals who have previously been suicidal, made attempts, and sat in ED for countless hours). We have harnessed the power of this perspective which has transformed the Dr. Dave avatar experience into “Jaspr Heath” which is now a multipurpose tablet-based engagement experience that still features the CAMS-based SSI assessment and a version of CAMS intervention in the form of a Stabilization Plan. Dr. Dave is gone and has been replaced by a virtual guide named “Jasper” (a little cartoon character) or  a pleasant looking woman, by the name of “Jaz” (a much better alternative to my original avatar, which frankly, frightened my wife and kids).

Cams-care Image

“Jasper” or “Jaz” can then introduce a full array of options to engage the suicidal ED patient, including education about the ED experience and what to expect while they are there. Patients are offered access to a menu of “Comfort and Skills” which is content to help them learn new options for coping, ranging from DBT-inspired coping skills to comforting video content of puppies playing, a crackling fireplace, to distracting techniques, etc. There is also an option to engage in video content of people with lived experience who provide hope and inspiration through their own stories of despair and redemption and lessons learned.

The Jaspr Health patient engagement ultimately produces a detailed report for busy ED providers that provides key assessment information about the patient’s suicidal risk, their CAMS-inspired Stabilization Plan, information about their access to lethal means (and willingness to secure such means), and further considerations that should help shape and inform an optimal disposition plan for the patient. For their engagement with Jaspr, patients are provided a digital companion app of their “favorite” content from the Jaspr engagement that they can download to their smart phone or laptop.

To get a taste of the Jaspr experience, check out a 2 minute YouTube video at:  https://www.youtube.com/watch?v=l9zbM8jEsvY&feature=youtu.be)

As per Phase II, in the last year we began using Jaspr Health in a rigorous RCT within ED care at the famed Mayo Clinic in Rochester MN. It is fair to say, that doing ED-based research is challenging even in the best of circumstances. But adding the worldwide COVID-19 pandemic to the mix made our ED-based research impossible to further pursue and the RCT was abruptly interrupted in March to accommodate needed ED space and focus on COVID-19 patients. With about a third of the sample recruited, we went ahead and did a preliminary analysis of the 30+ ED patients that had been engaged in the RCT prior to COVID-19 preempting further RCT data collection. With limited statistical power (due to the small sample), we were nevertheless thrilled with significant and favorable findings fully supporting the use of Jaspr Health. I will leave the particulars for a later blog as the study and our preliminary results are now under review in a paper that we recently submitted to a peer-reviewed journal. But suffice it to say, even we were stunned by the incredibly positive results from suicidal ED patients’ engagement with Jaspr. We are planning to continue the Jaspr RCT when the COVID-19 transmission and infection rates become more stable.

The Jaspr research experience has been an unexpected gift within my professional life. I have never been particularly savvy with technology and as a provider and professor of clinical psychology, I am very biased to favor a live person-to-person clinical engagement between a provider and patient. But the Jaspr experience has taught me new lessons about what can work in the service of saving lives. The technology of Jaspr is impressive. The ED experience is uniformly negative, but the Jaspr engagement makes it much more tolerable and ensures that time in the ED a productive and valuable experience for the patient with benefits for busy ED providers as well.

These benefits of Jaspr need not end as the patient leaves the ED because they will have access to Jaspr-based content that is downloaded to their phone or laptop. I am a pragmatist, and with 10,600,000 adult Americans struggling with serious suicidal ideation each year, we need any and all help possible to address that suffering in the service of saving more lives from suicide. As our research continues to unfold, I am convinced that Jaspr can play a key role in that pursuit.

Fear of Suicidal Patients and Taking the Risk to Care

Posted on by erics

A recent AAS listserv exchange got me thinking about the abject fear that many mental health providers feel about working with suicidal patients. I have written on this topic many times and I routinely talk about this in my professional trainings. For people outside the field, this is a shocking thought—how could mental health professionals possibly fear suicidal patients? It is their job to care for any and all types, right? It is akin to a primary care provider being afraid of patients with heart disease (the #1 killer in the United States). Right?

Yet the fear is there and to be honest, it is not unreasonable; I myself have felt it. Being counterphobic, it is probably one of the biggest reasons I became an expert on suicide so I could feel some sense of mastery towards something that frankly makes me anxious and feel wary (not unlike becoming a technical rock climber in college to address my fear of heights). And yet I have managed to see and work with hundreds of suicidal people over 35 years of practice.

But in fairness to the fearful, let’s be candid: according to research, the vast majority of mental health providers receive little to no formal curricular training in the assessment and treatment of suicidal risk. Moreover, in our litigious society, the prospect of a family pursuing malpractice litigation is a very real and daunting threat. Many years ago, one of my students was involved in an interesting survey study wherein the majority of suicide loss survivors who lost their loved one (who was engaged in mental health treatment at the time of their suicide) perceived the death to be a result of clinical malpractice. Moreover, a significant subset of the sample reported actually contacted a plaintiff’s attorney to explore the prospect of malpractice litigation. It is therefore not a mystery as to why providers are scared and avoidant—they have not been trained to work with suicidal risk, and if they clinically “fail” there is the prospect of being sued for malpractice negligence.

The AAS listserv discussion initially focused on the notion that our legal system is the problem. In other words, considering the real and objective threat of litigation, there is a clear disincentive to working with challenging cases, particularly if they are suicidal. A psychiatrist on the listserv usefully noted that surgeons routinely turn away particularly challenging, low-probability-for-success procedures and no one really questions this aspect of surgical care (this psychiatrist was not defending the practice, just providing a point of reference).

This comment took me back some years ago when my oldest brother was facing an extremely high-risk heart valve procedure after a lifetime of battling cancer. In a professional and direct manner, his world-class surgeon said that my brother had perhaps a 15% chance of surviving an extraordinarily complex surgery. He said that it would be well within his practice parameters to decline such a high-risk case, noting it could “…hurt my batting average” (meaning that fatal surgical outcomes negatively impact his overall success rate). Please know that he did not say this cruelly or insensitively; he was just candidly stating the facts of the situation. In turn, we were not offended, and we understood clearly. But we nevertheless begged him to take the risk anyway and he eventually agreed. I can assure you that we signed a stack of legal documents designed to discourage litigation should there be a poor outcome. Sadly, my brother did not survive post-operatively. But here is the point: it never once occurred to us to sue him for malpractice. To the contrary, we were so grateful for the surgeon’s courage to take on my brother’ exceedingly difficult case. In fact, my sister-in-law visited the surgeon later that year to personally thank him for his heroic efforts to try and save her husband’s life.

I share this personal anecdote as a means of underscoring a larger need to realign how we think of high-risk clinical care. It is understandable that some healthcare providers may avoid such patients out of fear of failure and the pervasive blame-game that seems almost automatic when there is a poor outcome. But why can’t mental health professionals work more like my brother’s surgeon? Acknowledging to the patient and their family the full range of potential outcomes. Why can’t families sign a stack of forms that create some measure of legal top cover so providers feel like they can take the risk to care?

An obvious solution to all this was posted on the listserv by CAMS-care President, Andrew Evans. His post suggested that there might be much less blame and litigation if mental health providers would simply use one of the handful of suicide-focused clinical interventions proven to work by replicated randomized controlled trials (e.g., CAMS). Such interventions also embrace the importance of clinical documentation and professional consultation (both of which reflect good practice and help decrease liability).

To this end, I am reminded of a college student’s suicide, who had been previously seen in his university counseling center where he had received an extensive course of CAMS-guided care. Unfortunately, he dropped out of treatment and was non-responsive to a handful of efforts to get him to return to counseling center care. Following his suicide, his enraged father brought a high-priced plaintiff’s attorney to meet with his son’s therapist and the director of the counseling center. During the tense meeting the director presented the clinical record replete with CAMS Suicide Status Forms and detailed notation of the provider’s extensive efforts to get the patient to return to care. The lawyer closed the record, looked at the father and said: “…we have no case…there is simply no negligence here to go after.” The furious father hired two more attorneys who both came to the exact same conclusion.

My friend and colleague Susan Stefan (a premier mental health legal scholar) and I have occasionally talked about the prospect of creating legal documents—a waiver of sorts—for mental health providers to use with patients and their families that might help assure some degree of protection for clinically engaging high-risk suicidal patients. Such a waver would not necessarily make a provider “bullet proof” from malpractice litigation, because there must be consequences for reckless and negligent clinical care. But similar to the documents that we signed with my brother’s surgeon, short of gross incompetence or clinical negligence, the family would not frivolously sue because of a fatal outcome. More to the point, such a waver might help decrease mental health providers’ abject fears of seeing suicidal patients while increasing their willingness to take the risk to care – and potentially save more patient lives from suicide.

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