Author: erics

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.

Related Articles:

Suicide Malpractice Statistics

Mental Health Malpractice:  Greatest Fear of Care Providers

Mental Health Providers:  Top 5 Ways to Limit Malpractice Exposure

Obstacles to Suicide Prevention and Treatment Training

Posted on by erics

Suicide claims one person in the U.S. every 12 minutes, according to the CDC. That’s 123 lives lost each day in America alone.

Many of these people reach out to or are referred to counseling or other treatment and interventions intended to prevent an eventual death by suicide, but unfortunately – and despite the best of intentions – most of these therapists and professionals are undertrained (or not trained at all) and ill-equipped to effectively help these troubled individuals.

Two major obstacles stand in the way of developing and delivering effective training for those in the suicide prevention and treatment field:  insufficient funds availability and a lack of national standards.

Lack of Funding for Suicide Prevention and Treatment in General

As pointed out in a 2018 article by USAToday, although the CDC reports that suicide is the 10th leading cause of death in the United States, and the second leading cause of death in youth, funding for suicide prevention and treatment lags behind other top killers.

In fact, according to NIH, Centers for Disease Control and Prevention, more funds are available for vision disorders, intellectual and developmental disabilities, sleep research, and dietary supplements than for suicide prevention – all associated with conditions having much lower mortality rates than death by suicide.

Additionally, with the exception of accidents, the same study shows that the leading causes of death have declined since 1999, while the suicide rate has increased by 33.3%.

Suicide Rate Chart

Conducting research projects and completing randomized controlled trials (RCTs) needed to determine effective prevention and treatment methods can be expensive, and the costs of developing evidence-based and outcome-based programs and running treatment centers are prohibitive for many organizations.

With this lack of funds for suicide assessment and treatment in general, it follows that training in effective assessment and treatment is also lacking – and that is certainly distressing for those in this field.

No National Standards Requiring Training for Suicide Prevention and Treatment

As reported in the American Journal of Public Health, a study completed in 2017 found that only ten states currently mandate training for behavioral healthcare professionals in how to spot risk for suicide and take preventative action. Furthermore, there are no national standards requiring training. The study identified the following:

  • # of states with policies mandating and encouraging suicide prevention training for healthcare professionals:  2
  • # of states with a policy mandating suicide prevention education for healthcare professionals:  8
  • # of states with a policy encouraging suicide prevention education for healthcare professionals:  5
  • # of states with a policy mandating or encouraging training for the treatment for suicidal patients for healthcare professionals:  0

The same report, which emphasizes deficiencies in mental health training, asserts that accrediting organizations must include suicide-specific training and education in their graduate programs, and furthermore, the government should require such training for healthcare systems receiving state or federal funds.

The Dangers of These Obstacles

We all want to help, but the fear of doing or saying the wrong thing and failing to effectively treat a person in need can have devastating effects.

In fact, with no other option in sight, poorly trained therapists often resort to referring suicidal clients to the emergency room. However, studies show that emergency department presentation and admission into psychiatric hospitalization can actually increase the risk of a lethal outcome in people with suicidal ideation.

In addition to a fear of failing to successfully treat a suicidal client, there’s also the concern of exposure to malpractice liability and the risk of losing one’s license to practice. In their confusion and grief, families of suicide victims often look for external causes for the loss of their loved ones, sometimes landing on the actions or inactions of those who were meant to help.

Too often, these fears leave suicidal patients without the care, treatment, or interventions that they so desperately need.

Overcoming Obstacles to Training

If suicide were more commonly and widely viewed as a leading public health issue, as other leading risks are, perhaps more funds would be allocated to suicide prevention and treatment, and more focus would be put on developing standards for effective training.

In the meantime, CAMS-care offers training in the evidence-based and outcome-based Collaborative Assessment and Management of Suicidality (CAMS) Framework, developed by Dr. David A. Jobes over the course of the last 30 years.

With a robust base of clinical trial research, the CAMS Framework® presents a collaborative approach to suicide assessment, intervention, and treatment. Flexible and affordable training, available both online and onsite, helps healthcare providers and other individuals become more confident in their ability to help their clients and patients with suicidal ideation and risk and avoid lethal outcomes.

Self-Determination Theory (SDT) and the CAMS Framework® of Evidence-Based Suicide Prevention

Posted on by erics

I was recently reviewing some literature for a current study and happened to come across a newly published conceptual article by a scholar named Édua Holmström, who is at the University of Helsinki in Finland. The article was a marvel to me as Holmström’s paper uses the “Self Determination Theory” (SDT) to conceptually explain how the CAMS Framework of suicide prevention motivates suicidal individuals to choose life.

The Power of CAMS

Those who use the CAMS framework with suicidal patients already know that it first and foremost is based on empathy & honesty, and encourages your clients to work collaboratively with you to develop their unique suicide-focused treatment plans. This paper shines a light on this important element of the CAMS approach to treatment, and theorizes that this autonomy and acknowledgment of the client’s ability to make decisions about their own treatment plan is the key to the effectiveness of CAMS to clinically help save lives.

Applying Self-Determination Theory to CAMS

It turns out that SDT elegantly describes certain key aspects of this spirit and embodies the essence of doing CAMS as a collaborative and empathic therapeutic patient-centered framework. Within CAMS there is a clear and overt emphasis on respecting and validating the suicidal patient’s autonomy, a central construct within SDT. Writing about CAMS, Holmström notes “…many suicidal individuals make informed decisions about treatment with the support of an empathetic clinician.”

I could not agree more. And it is exhilarating to read the reflections of an unmet scholar in a faraway land applying a novel theory (at least to me) as explanatory for this evidence-based approach to suicide intervention that has consumed me over my entire professional career. Even after 35+ years in the field I cannot begin to describe the unabashed excitement I felt discovering this beautifully written paper about something that is so near and dear to my life’s work, and it got me thinking…

I often say to my students, “There are no new ideas, just repackaged old ones that capture enduring truths.” Over the years I have heard variations on this notion as it relates to CAMS. A seasoned and savvy inpatient nurse during a training session once told me that CAMS was nothing new, it was simply good nursing! She was delighted when I agreed and shared that I began my professional career on inpatient nursing staff as a psych tech. Her response? Of course, you did, I knew it! Some years later I had a similar conversation with a sophisticated clinical social worker who insisted that the essence of CAMS was merely doing good clinical social work!

Over decades I have come to relish many such conversations with clinicians across disciplines who have said in some way or another that they have been “doing CAMS” for years without realizing it. I think of my friend Kevin Briggs, who was a CHiPS highway patrolman for many years. His beat was the Golden Gate Bridge, and in his book, Guardian of the Golden Gate Bridge, Kevin recounts incredible experiences of talking suicidal of people out of jumping to their deaths from the iconic bridge. He could not save them all, but he literally did help save hundreds of lives. Over coffee, Kevin once told me that he used to lie down on the pavement to be at the same level with certain prospective jumpers sitting on a pipe on the other side of the railing so he could talk to them at their level. He asked me: So, was I doing CAMS? My response: Kevin, you are a natural!

Benefits of Evidence-Based Treatment

Many of my days are consumed with randomized controlled trials (RCTs), interpreting data, and writing scientific papers in my determined effort to prove that CAMS works through replicated RCTs with the highest rigor of science possible. It is my passion and my goal to well establish a solid place for CAMS within systems of care as a means of clinically saving lives for people on the brink of life.

But when I read this article from a faraway land explaining to me how my intervention works, it gave me pause to think. I reflected on many conversations over decades with clinicians about how to help save lives. And I reflected on some simple and enduring truths about life. Most people want to live a life with purpose and meaning; most do not desire death by suicide. But for those who do, simple ideas about autonomy, empathy, collaboration, and truth go a long way toward creating the possibility of saving a life, even in the face of suicidal despair. “Good nursing” or “good social work” can help transform lives and help people self-determine whether they live or die.

It is gratifying and humbling to see an outside source confirming the importance of self-determination concepts as potential cornerstones of CAMS.