Authors: David A. Jobes Ph.D. ABPP

David Jobes, PhD, ABPP, is the founder of CAMS-care, LLC. He began his career in 1987 in the Counseling Center of the Catholic University of America, where he developed a suicide risk assessment tool for college students that evolved into CAMS. Dr. Jobes is now a Professor of Psychology and Associate Director of Clinical Training at Catholic; he has trained thousands of mental health professionals in the United States and abroad in evidence-based assessment and treatment of suicide risk and the use of CAMS.

10 Tips for Clinical Management of Suicide Risk

10 Tips for Clinical Management of Suicide Risk On-Demand Webinar

In this hour-long webinar, “10 Tips for Clinical Management of Suicide Risk,” clinicians often face anxiety and uncertainty in managing and treating suicide risk. This presentation will highlight ten helpful and scientifically informed tips that clinicians can begin to use immediately in the context of their practice.

Marjan G. Holloway, Ph.D.

About Marjan G. Holloway, Ph.D.

Dr. Holloway is a Professor of Medical and Clinical Psychology and Psychiatry at Uniformed Services University (USU), a Diplomate of the Academy of Cognitive Therapy, and an Adjunct Faculty Speaker and Consultant at the Beck Institute for Cognitive Behavior Therapy and the Zero Suicide Institute. She completed her postdoctoral training in 2005 at the Center for the Treatment and Prevention of Suicide at the University of Pennsylvania under the mentorship of Dr. Aaron T. Beck. As the Founder and Director for the USU Suicide Care, Prevention and Research Initiative, Dr. Holloway and her team have developed and disseminated a number of evidence-informed psychosocial programs to address the public health burden of suicide as highlighted by (1) the Air Force Guide for Suicide Risk Assessment, Management, and Treatment; (2) the Chaplains-CARE program; (3) Special Operations Cognitive Agility Training (SOCAT); (4) Rational-Thinking and Emotional-Regulation through Problem-Solving (REPS) for newly enlisted military personnel; (5) Mil-iTransition for Service members receiving unfit for duty determinations; and (6) Post-Admission Cognitive Therapy (PACT and PACT-Together) for psychiatric inpatient settings and Intensive Outpatient Programs. Dr. Holloway maintained a part-time private clinical practice for 15 years, shifting recently to a consulting practice.

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The Stepped Care Model in Clinical Suicide Prevention

Posted on by erics

According to the CDC, 12.2 million Americans seriously thought about suicide in 2020. 1.2 million actually made suicide attempts. With nearly 46,000 deaths per year, suicide remains a leading cause of death in the United States with rates of suicide steadily increasing over the past decade. Yet despite this health care emergency, mental health systems of care are largely underprepared to work effectively with suicidal individuals.

In response to these concerns, a recent policy initiative called “Zero Suicide” has advocated a systems-level response to the suicidal risk within health care and this policy initiative. And it’s working.

A “stepped care” approach has been developed and adapted to work within the Zero Suicide curriculum as a model for systems-level care that is suicide-specific, evidencebased, least-restrictive, and cost-effective. The Collaborative Assessment and Management of Suicidality (CAMS) is an example of one suicide-specific evidence-based clinical intervention that can be adapted and used across the full range of stepped care service settings.

This article describes several applications and uses of CAMS at all service levels and highlights CAMS-related innovations in the stepped care model. Psychological services are uniquely poised to make a major difference in clinical suicide prevention through a systems-level approach using evidence-based care such as CAMS. Here’s how stepped care can improve the effectiveness and efficiency of suicide care.

What is a Stepped Care Approach?

Stepped Care is a system of delivering and monitoring treatment so that the most effective and efficient treatment is delivered to patients first. Patients only “step up” to intensive/specialist services when it’s clinically required.

For example, a stepped care model for suicide care usually starts with suicide or crisis hotline support and follow-ups, like the 988 Suicide Helpline. This is followed by more involved and thus more costly and less easily scalable interventions like: additional follow-ups, emergency care, hospitalization, and finally specialist inpatient psychiatric care or hospitalization.

stepped care model

The goal of stepped care is to use evidence-based assessments, treatment plans, and patient tracking to allow the right people to deliver the right treatment in the right place at the right time to meet each patient’s needs.

Applications and Use of CAMS Across the Stepped Care Model

Suicide prevention and treatment is an immensely complicated and ever evolving field. However, thanks to evidence-based assessment and treatment frameworks, like The Collaborative Assessment and Management of Suicidality (CAMS) and tools like the Suicide Status Form (SSF) which is becoming a part of electronic health records across the country, clinicians can be more equipped to identify, treat, and ultimately prevent suicide.

CAMS has more than 30 years of evidence, five published randomized control trials, and two meta analyses one of which shows that CAMS is a “Well Supported” treatment by CDC criteria and is even proven to “reduce hopelessness and increase hope” in as few as six sessions. In fact CAMS is one of four evidence-based treatments that are referenced by the Joint Commission, Surgeon General and the CDC.

Click here to learn more about how we train physicians to use CAMS to treat and prevent suicide.

Crisis Hotline Support

Staffed by well-trained and compassionate professionals, suicide crisis lines are incredibly important tools in suicide care and prevention. They have the unique ability to provide vital crisis support to a range of suicidal individuals from all walks of life. But more importantly, crisis lines can effectively help suicidal individuals who may not be able to afford or even need costly clinical interventions.

CAMS can be a useful resource for call centers, since crisic center work typically focuses on assessing the immediate risk of suicide or suicidal thoughts through collaborative dialogue. The Suicide Status Form (SSF) is also a well-suited therapeutic assessment tool to efficiently stratify the level of risk during a crisis call, thanks to its easy to learn, structured, yet non-directive framework.

The SSF can also be used to track the ongoing risk of repeat callers, providing continuity of care when multiple crisis workers speak with the same caller over a period of time across shifts. Recent use of crisis text and chat lines present additional opportunities for using the SSF as a framework for collaborative suicide-specific engagement.

Brief Intervention

Emergency departments are often responsible for identifying, performing risk assessments, and referring suicidal individuals to specialist care, often in a high-volume, high stress environment. That’s a lot to ask from ED practitioners. That’s why we developed CAMS Brief Intervention (CAMS-BI™) to help meet this demand.

CAMS-BI is a single first session of CAMS using the SSF to learn about the patient’s suicide risk and the drivers of their suicidality, which leads to the development of a CAMS Stabilization Plan. CAMS-BI can be linked to non-demand caring follow-up contact in any way that’s agreeable to the patient including phone calls, text messages, e-mail, letters, etc. Emergency departments can also give out a Coping Care Package that includes various resources for patients to use after release.
Outpatient Settings

It’s essential for clinicians to attend to, assess, and treat suicidal risk in any mental health service setting. But the Suicide Status Form was originally developed for outpatient care, which means that CAMS is particularly well-suited for general outpatient mental health care services.

CAMS can help mitigate concerns regarding suicidal patients “falling through the cracks” by providing valuable structure and tracking support for both patients and clinicians. CAMS has even been adapted for use in several outpatient settings, including university counseling centers, community mental health centers, employee assistance programs, private practices, military, and Veterans Affairs behavioral health settings, and even successfully adapted to accommodate cultural considerations for use in countries around the world (Lithuania, China, Western Europe, and Australia).

Here is how CAMS is improving stepped suicide care in various clinical settings.

University Counseling Centers

CAMS has been successfully used in university counseling centers for years, and has proven to be especially adaptable to the unique culture of college life. One of the biggest strengths of CAMS on college campuses is how it integrates available resources in the university setting into the framework.

Empowering resident advisors, student-run organization, campus ministry, and health care services with the resources they need to help intervene with certain suicidal drivers and participate in the therapeutic process increases campus-wide awareness of suicidal risks while making the assessment and treatment stages of the process more efficient and effective for everyone involved.

Community Mental Health Centers

Clinicians working in Community Mental Health Centers often face unique challenges not limited to large case-loads, a chronic lack of resources, and an array of complex cases. CAMS can offer solutions to many of these challenges.

In a large-scale 5-year roll out of CAMS across the state of Oklahoma, CAMS was effectively adapted for CMHC patients with psychotic disorders and developmental delays. CAMS also increased hope and reduced suicidal ideation and overall symptom distress for outpatient CMHC patients, 40% of whom were homeless.

Independent Practice

Many clinicians in independent practice may feel particularly vulnerable and isolated when working with suicidal patients as they may not have access to various resources or a team of colleagues to help provide services and professional support. CAMS can provide clinicians with a clear procedural outline for assessing, treating, and tracking a suicidal patients’ progress, with tools like the SSF to increase their confidence and effectiveness at identifying and treating suicidal thoughts and ideations.

Military

Suicide remains a significant problem in the U.S. military, with many military Behavioral Health Clinics lacking a system for tracking ongoing suicidal ideation. As a consequence of this care gap many service members experience psychiatric hospitalization, which is not only inefficient, but often ineffective as suicide-specific treatment is typically limited.

Given the scope and scale of the problem, CAMS’ evidence-based, adaptable framework for assessing, tracking, and treating suicidal risk can provide an effective and scalable solution within military treatment facilities.It also addresses one of the biggest challenges for suicide care in the military — service members may not stay in one location long enough to complete a lengthy treatment protocol.

To help tackle this, CAMS aims to efficiently resolve suicidality in as few as six to eight sessions, and there’s a growing interest in the use of CAMS for military populations through telehealth.

Like standard CAMS, telehealth allows clinicians and behavioral health specialists to work together by jointly following the SSF as their clinical road map. Given the large number of service members who may not be able to access a treatment facility due to deployment, residing in remote areas, or physical disabilities, telehealth may provide a viable alternative to standard care. And many younger military members may also prefer a telehealth treatment option.

Veterans Affairs Outpatient Settings

Over many years CAMS has been extensively trained to providers across VA mental health treatment settings including VA medical centers and Community-Based Outpatient Clinics (CBOCs).

VA clinicians have a keen interest in the model and suicidal veterans anecdotally find the model helpful, but further clinical trial research is needed which is now being pursued by our research team.

Emergency Respite Care

As mentioned earlier, over the past several years, the state of Oklahoma has embraced the Zero Suicide policy model and has sought to systematically train CAMS to providers in their public mental health system. As part of their process improvement initiative, hundreds of outpatient providers and clinicians who work in brief intensive respite clinics have been trained to use CAMS in places where suicidal patients are stabilized over a 48-hr period and then discharged.

In the optimal care transition model, CAMS is initiated within crisis respite care to help stabilize the patient who is then discharged to a CAMS-trained provider who can continue the CAMS-guided care initiated in respite in an uninterrupted manner on an outpatient basis.

Partial Hospitalization

There has been some interest in using CAMS within partial hospitalization service settings. For example, there was some early clinical use of CAMS within a group format for severely mentally ill patients in a day treatment program within a VA Medical Center.

Partial programs offer intensive treatment in a more cost-effective and least-restrictive form of care. So it seems inevitable that CAMS will increasingly be used in such settings in the years ahead as a viable alternative to more expensive inpatient psychiatric care.

Inpatient Psychiatric Hospitalization

Within the current system of mental health care, individuals who are at imminent risk for suicide are often referred for inpatient care. And while the inpatient psychiatric setting may provide a safe and supportive environment for specific acute care services and stabilization, most of the interventions provided to suicidal patients are neither suicide-specific nor evidence-based.

In a report from the Suicide Prevention Resource Center (SPRC) and SAMHSA DJ Knesper noted:

“. . . the research base for inpatient hospitalization for suicide risk is surprisingly weak. This review could not identify a single randomized controlled trial about the effectiveness of hospitalization in reducing suicidal acts after discharge”.

Thankfully, this is changing as adaptations of the SSF and CAMS are being used to effectively assess and treat suicidal risk within inpatient settings. Most notably, the Mayo Clinic has used the SSF assessment to inform inpatient treatment and disposition discharge planning, and has further integrated the SSF into their routine assessment used with all patients at admission.

In terms of treatment, a Swiss team created an inpatient version of CAMS that was associated with dramatic decreases in overall symptom distress and suicidal risk in a sample of 45 suicidal inpatients over the course of 10 days of inpatient care.

Our team is currently exploring the use of an intensive inpatient version of CAMS, called CAMS Intensive Inpatient Care (CAMSIIC) which has been used in several inpatient treatment settings within the U.S. over a 3- to 6-day hospital stay. CAMS Brief Intervention involves conducting Session 1 of CAMS during a brief inpatient stay necessitates the development of a stabilization plan, discussions of access to lethal means, and preliminary identification of issues in need of treatment (i.e., suicidal drivers) all of which should be quite relevant to the disposition of the patient upon discharge.

An adapted inpatient version of CAMS has also been used successfully at the Menninger Clinic in Houston, Texas. Referred to as CAMS-M, this adaptation offers CAMS twice per week with highly suicidal inpatients over a 50- to 60-day stay with clinicians focusing on intensively treating suicidal drivers while the nursing staff focuses on stabilization planning. The entire team then focuses on meaningful suicide-specific disposition and discharge planning.

In an initial open trial, a case series investigation of the effectiveness of CAMS within this longer-term inpatient psychiatric setting found statistically and clinically significant reductions in depression, hopelessness, suicidal ideation, and improvement in relation to suicidal drivers for 20 inpatients (Ellis, Green et al., 2012). A second study at the Menninger Clinic found significant changes in overall suicide ideation and suicide-related thoughts.

How CAMS Helps Diverse Populations

As a flexible clinical framework, CAMS has proven to be uniquely adaptable and modifiable to meet the needs of different patients, providers, and systems of care in the “real world” of psychological services. This adaptability has lead to CAMS being used to help diverse patient populations from suicidal inpatient teenagers at Seattle Children’s Hospital to suicide-specific group therapy within VA health care settings, and even the California state prison system and juvenile justice facilities in Georgia.

A systems approach to suicide prevention has clearly emerged as the best means for raising the overall standard of clinical care for suicidal patients with the promise of saving lives. Zero Suicide is a game-changing policy initiative that is gaining traction in the U.S. and abroad.

We have presented a stepped care model of suicide that is designed to treat suicidal risk in an evidence-based, least restrictive, and cost-effective manner. Moreover, we have shown the potential value of applying and using the CAMS evidence-based approach across the full range of psychological services—from paraprofessional interventions, to outpatient settings, to respite care, to partial care, and to inpatient psychiatric care.

CAMS may not work for every suicidal patient or setting, but it is highly adaptable and effective for a range of suicidal patients across systems of clinical care. Given that suicide is the fatality of mental health care, we urge members in our field to do all that we can to enhance our abilities to effectively assess and treat suicidal risk across the full range of organized health care settings to help save lives.

Contact us to learn more about CAMS training and a range of applications for CAMS and the SSF for clinicians and providers across the world.

Office Hours with Dr. Jobes

“I have attended a majority of the monthly meetings since they started and look forward to attending each month. As the only CAMS trained clinician in my agency, the meetings have been invaluable. The opportunity to collaborate with other clinicians and Dr. Jobes has increased my confidence as a clinician using CAMS.”

Renee Lips-Bush, LICSW, LADC

Benefits of Attending Office Hours

These quarterly meetings are an opportunity to talk with Dr. Jobes and other clinicians about

  • patient cases
  • questions you have about implementing the CAMS Framework®
  • keeping up with the latest research in the caring for patients with thoughts of suicide.
  • updates in working with teens
  • forms for treating Drivers
  • articles on the field of suicidology

Who is Eligible to Attend

Clinicians who are CAMS Trained™ and on the CAMS-care Locator.

Upcoming Meeting Times for Office Hours with Dr. Jobes

February 6, 2025 12:00pm ET

May 2, 2025 12:00pm ET

Registration is sent out to Clinicians on the Locator a month before the training. If you are on the locator and have not received an invitation, contact support@cams-care.com.

Clip from Office Hours with Dr. Jobes

CAMS-4Teens®

Posted on by erics

Upon reflection, probably the single biggest request that we hear from providers in the field is a desire to use CAMS with adolescents and even young children who are suicidal. As a treatment researcher, this demand has been challenging because we simply do not yet know the full impact of CAMS on youth based on randomized controlled trials (RCTs) with replicated results and independent validation. While we do have excellent RCT data supporting CAMS for adults and supportive data with older adolescents who are in college, we do not yet have extensive data on younger teens or children who are suicidal.

Research so far on using CAMS with youth

So what do we know empirically so far? In our college student Randomized Control Trial (Pistorello et al., 2020) the average age of patients receiving CAMS was 19 and we saw significant reductions in suicidal ideation and overall symptom distress caused by CAMS (when compared to usual care). We also saw significant reductions in hopelessness for certain students in comparison to control care. We also know from Dr. Amy Brausch’s psychometric research that the Suicide Status Form (the SSF is the key multipurpose tool used in CAMS) is both valid and reliable when used with adolescents who are suicidal. Several published papers about the use of the SSF and CAMS with teens and even children have appeared over the years. Under the leadership of Dr. Molly Adrian, we have recently published a small clinical trial of CAMS with teens at Seattle Children’s Hospital showing positive effect sizes related to reducing suicidal ideation and showing that using CAMS was both feasible and acceptable to both adolescent patients and their providers.

The scientist in me says wait; the clinician in me says proceed with caution

But the dilemma for me has been related to promoting the use of “CAMS-4Teens” prior to having robust and supportive RCT findings (along with replication of RCT results and independent validation by other clinical researchers). The good news is that there are now three funded NIMH RCTs of CAMS that will help provide those exact outcome results. The bad news is that such data will not be published for 5-7 years at the earliest. Clearly, clinical trial research proving a treatment actually works—and is not harmful—is a painstaking process and not for those who are inpatient for such results! So, do we deny the use of CAMS for another several years awaiting the findings of funded and well-powered RCTs? The scientist in me says let’s wait. But the clinician/pragmatist in me says let’s proceed with caution promoting its use based on what we know from research thus far and our best recommendations about what is likely to work going forward. And to this end, we actually know a fair amount and we are now moving ahead to train clinicians in CAMS-4Teens as best we can based on what we know so far.

Promising data for evidence-based treatments for youth

One thing that I will note is that we see promising data in some suicide-focused “cousins” to CAMS that providers may consider using. There are good data (sometimes mixed but overall supportive) for using Dialectical Behavior Therapy (DBT) with adolescent populations (developed by Dr. Marsha Linehan). In addition, I am a fan of Dr. Guy Diamond’s Attachment Based Family Therapy (ABFT) which has decent RCT support for reducing suicidal ideation among teens within Guy’s lab (independent RCT replication is pending). But beyond these two approaches there is little else available that has robust RCT support.

Three funded RCTs are in progress using CAMS with youth

In terms of CAMS, I have frankly have little to no concerns about using the framework with teenagers. Along with other colleagues I have used CAMS for years with youth and seen how powerful this patient-centric, suicide-focused, intervention can be for adolescents who are suicidal. Beyond our “CAMPUS” clinical trial, two new RCTs specifically focused on teens show tremendous promise thus far. The first is the “Keta-CAMS” RCT being conducted at the Cleveland Clinic and Mass General Hospital. This RCT randomizes inpatients who are acutely suicidal following a suicide attempt. Half of the sample receive 1 to 6 intravenous does of Ketamine (the control sample receives IV doses of saline) and all patients in the trial receive an initial session of CAMS-4Teens prior to discharge and up to 7 more outpatient sessions of CAMS via telehealth (during the high risk post-discharge period). This study is intended to test a potential synergistic effect of an active medication which may enhance the clinical impact of CAMS (as compared to placebo control). The second major NIMH-funded RCT is called “ASSIST” which randomizes outpatient teens who are suicidal (at Seattle Children’s Hospital and Nationwide Hospital in Columbus OH) to either CAMS-4Teens vs. Safety Planning + (developed by Drs. Barbara Stanley and Greg Brown) vs. treatment as usual. Both of these multisite RCT’s are just now starting up and we have hammered out some procedures, particularly related to parents, that are important to share at this early juncture.

How do we best involve parents?

As a patient-centered intervention, CAMS philosophy requires that the teenager is the focus of all clinical care. To this end, we aim to discourage “back door” discussion with parents that do not include the adolescent patient. It is critical for the child to perceive the CAMS clinician as THEIR provider, not their parent’s. We see this as an essential dynamic which is designed to win the trust of the adolescent patient. In other words, if the teen sees their clinician is communicating everything they share with the parents (without their being privy to such discussions) they will naturally be less candid with their provider. However, to varying degrees, clinicians in these two RCTs are ambivalent about not having a separate line of parent-only communications. In turn, parents might feel left out or threatened by not know what is going on with their child and teens may fail to disclose key information that may be crucial for the provider to know. What to do? How do we earn the child’s trust but still get parental buy-in and support of the treatment which by its nature will be defined by the child-patient’s perceptions and needs vs. the parents’ agenda for their child? How do we secure lethal means in the family home that may occur better as a separate conversation with parents vs. the child being made aware of potential dangers in the home about which they may not know? Through some hard discussions, I believe we have landed on initial answers to all these key questions.

The role of the parents supporting their child’s treatment

First up, there needs to be a parent-only engagement, before engaging the teen in their first session of CAMS. In other words, CAMS-4Teens in these trials will begin with a parent-only meeting to help orient them to the intervention, set expectations, and provided guidance for their role in their child’s care. This 15-20-minute discussion makes the following clear: as your child’s provider, I have the suicide issue that will be our singular focus within this treatment. In turn, your job as parents is to support this suicide-focused treatment that is designed to save your child’s life! The discussion then shifts to ensuring that the home environment is made as safe as possible. This involves the use of a new tool called the “Stabilization Support Plan” which methodically reviews potential access to firearms, medications, and any other lethal means in the home environment. Once this lethal means discussion has occurred and all questions have been addressed, the parents leave and the teen comes in for the first session of CAMS. Following completion of the end of the first session of CAMS, the parents are brought back to rejoin the clinician and their child to review the teen’s treatment plan including their CAMS Stabilization Plan and the two problem/drivers of suicide and interventions that will be used to treat these drivers. The second page of the Stabilization Support Plan is then completed with parents and the teen as to how the parents can best support/engage their child if a suicide crisis occurs. We thus allocate 1.5 hours for this critical first session; thereafter parents will be engaged at the end of each interim session to review the work and address questions as well as playing a key role towards the end of the final outcome disposition session as well. Across CAMS-guided care, we discourage the parents from trying to communicate separately with the provider (but for unusual or emergent issues) to minimize any perception of a back-door level of communication that does not include the child-patient.

I am quite pleased with the negotiations and compromises that we made to work out this protocol for working with parents, which to me has always been the “wild card” of working clinically with youth. Sometimes parents are the greatest resource and ally for care you can have; other times, parents can undermine, fight, or even sabotage their child’s care (often because of fear, embarrassment, and feeling out of control). I am pleased to note that we have recently filmed extensive video demonstrations of this protocol for working with parents and teens in unrehearsed/unscripted role plays. Our teen actors played characters based on peers they know and our amazing CAMS consultants were the adults playing parents. This new material is in the spirit of previous video demonstrations of “real world” issues that come up in clinical work with people who are suicidal, and this new training material will not disappoint!

Threading the needle between RCT support and the need to save young lives

Bottom line, as the RCTs march forward, we are not shying away from providing our best possible training guidance for using CAMS with young people who are suicidal. We are attempting to thread the needle of being fully informed by RCT evidence that has not yet been realized vs. the real-world needs of clinicians, parents, and teens to do something effective in the face of losing adolescents to suicide. Stay tuned for more research to come on CAMS-4Teens and for our foray into providing the best evidence and clinical practices for working effectively with this leading cause of death for our precious youth.

CAMS-4Teens®: The Complexities of Working with Parents

CAMS-4Teens®: The Complexities of Working with Parents On-Demand Webinar

In this hour-long webinar, “CAMS-4Teens: The Complexities of Working with Parents”, there are now three NIMH-funded randomized controlled trials (RCTs) using CAMS with young adults (college students) and adolescents who are suicidal. While CAMS has been used clinically for many years with these populations, RCTs on “CAMS-4Teens” are helping us discern the best possible ways for adapting the intervention and working with this population. Within our clinical trial research we are seeing various challenges–and the promise–of working with teens and their parents using a patient-focused intervention for suicide risk. Based on the early findings, CAMS-4Teens appears to be quite promising and developing ways to help parents to support their child’s suicide-focused treatment is evolving and compelling. This presentation provides an overview of the CAMS-4Teens approach along with an update on the current clinical trial research and emerging recommendations for effective clinical practice with adolescents who are suicidal.

Hosted by Dr. Kevin Crowley, clinical psychologist, private practitioner and CAMS Consultant.

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What Future? How People Who Are Suicidal Look Beyond the Present Moment

What future? How People Who Are Suicidal Look Beyond The Present Moment On-Demand Webinar

The consideration of suicide involves the contemplation of not only death, but also of life and what it can offer. This presentation explores cognitive underpinnings of life-oriented thoughts, with a particular focus on how people who are suicidal envision their future. Dr. Cha will introduce various ways to assess future thinking among individuals who are suicidal, and present an emerging profile of future thinking abilities that are characteristic of this population.

Christine Cha, PhD

About Christine Cha, PhD

Dr. Christine Cha is an Associate Professor of Clinical Psychology at Teachers College, Columbia University, and Director of the Laboratory for Clinical and Developmental Studies. Her research focuses on thought patterns that may contribute to suicidal thoughts and behaviors, and pertain to concepts proximal to suicide (e.g., death) as well as alternatives to suicide (e.g., future). Dr. Cha’s work has been funded by the American Foundation for Suicide Prevention and the National Institute of Mental Health (NIMH). She serves on the editorial boards of the Journal of Clinical Child and Adolescent Psychology, Journal of Abnormal Psychology, and General Hospital Psychiatry, and has received the Rising Star Award from the Association for Psychological Science.

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Cultivating Perspectives | Managing Suicidal Risk, 3rd Edition

Posted on by erics

Over decades of teaching clinical psychology Ph.D. students in graduate courses on clinical assessment, treatment, and theory one inevitably develops certain adages. One of my favorites that is central to successful psychotherapy is the “cultivation of perspective.” In other words, successful psychological care invariably includes a series of shifts in perspective in relation to how the patient thinks and feels which shapes and guides behavior over time. While this notion is central to effective psychological transformation, I also find it relevant to writing books.

The 3rd and Final Edition of Managing Suicidal Risk

A couple of weeks ago, I submitted the 3rd edition manuscript of Managing Suicidal Risk: A Collaborative Approach, which is now going into production to be published by Guilford Press in 2023. This is the final edition of a series for the source book on the Collaborative Assessment and Management of Suicidality (CAMS). With this newest edition, I’ve now written seven books on suicide prevention & treatment, and may continue to write more in the future. But this 3rd edition is special and feels like a fitting end of a 30+ year journey. With four ongoing randomized controlled trials (RCTs) underway and new trials in the works, there will be more journal articles and book chapters about CAMS. But for me, the 3rd edition feels like a final concluding paragraph to a story that I have been writing across the course of my professional life. Completion of this manuscript also marks the end of a yearlong sabbatical from my “day job” as a university professor. I can attest that sabbatical leave is one of the single greatest perks within academic life. As a university professor one is always immersed in the ebb and flow of ideas, data, theories, and constantly shifting perspectives—these are the stock and trade of a scholar’s life. So, to step away from that life to immerse oneself in a singular focused year of reading, researching, and writing is a meaningful alternative reality. As this sabbatical concludes, I am awash in musings about life, death, suicide, hope, hopelessness, purpose, meaning, and what ultimately makes life worth living during these trying times in the world.

The History Behind the First Edition of Managing Suicidal Risk

In 2004 I was elated to land a contract to write the first edition of my book with Guilford. In those days, my SSF clinical research and the nascent development of CAMS was garnering some attention. I was thus eager to promote key CAMS ideas that were novel and controversial in some quarters at the time. For example, the overt goal within CAMS to keep a patient who is suicidal, out of the hospital was not a widely embraced idea. The idea of making suicide the singular focus of clinical care (no matter the diagnosis) was greeted with wary skepticism. Eschewing the use of no-harm contracts in lieu of focusing on stabilization was only beginning to gain some traction in the field at that time. My research mentor, Marsha Linehan, was dismayed that I wanted to write a book before I had definitive randomized controlled trial (RCT) support for CAMS. While there were articles about the assessment aspects of the SSF, there was only one modest non-randomized controlled comparison trial of CAMS with U.S. Airmen who were suicidal. While the data was encouraging, Marsha flatly reproached me, “…you’re jumping the gun, get some RCT data and then write your book!” On the heels of being admonished by Marsha, I reached out to Ed Shneidman—another seminal influence—who was extremely enthusiastic about the prospect of my writing the first book, and instantly offered to pen the foreword to the first edition. For the record, Ed was always keen about the writing of books! In fairness to my friend Marsha, she would have been right had I only written the first edition. But I argued that I could write about the work to date while also pursuing future CAMS RCTs. Marsha saw my point and was extremely supportive of all my efforts to fully test CAMS with grant funded RCTs. Notably, she readily agreed to write the foreword to the 2nd edition of the book published in 2016, remarking on the importance of two published RCTs of CAMS at that time.

The Evolution of CAMS

The 2006 first edition of the book was frankly my version of a “hard sell” for what CAMS could become, largely based on the strength of our SSF assessment research. And while there are still those who mistakenly think of CAMS as a mere assessment tool (focusing on the first page of the SSF’s first session), I’m only too happy to dispel the misconception. I am regularly encouraging people to catch up to the 2nd edition which presented CAMS as a major clinical intervention focused on identifying, targeting, and treating patient-defined “drivers” of suicide. The 2nd edition therefore made a strong case for CAMS being seen as a suicide-focused therapeutic framework increasingly supported by the burgeoning RCT support in the U.S. and abroad. As of this blog’s writing in June 2022, there are now ten published open/correlational trials and five published RCTs. Importantly, a 9-study meta-analysis of CAMS published 2021 marked a watershed moment in the development and empirical support of CAMS. There are two supportive CAMS RCTs now under review for publication, and four more rigorous CAMS RCT’s are ongoing. Needless to say, I took Marsha’s feedback to heart! Moreover, I would say in hindsight that writing that first edition clearly spurred interest in the approach and poured fuel on the fire of CAMS clinical trials by my lab and other investigators.

Perseverance and the importance of Clinical Trial Investigations

I share this not as a self-congratulatory exercise but as a testament to both perseverance and the importance of clinical trial investigations. At 63 I feel blessed to have had such success raising CAMS from its infancy, and nurturing and parenting it into what it has become today.. For me, this work has always been first and foremost about the patients and their clinicians. Beyond this clear priority, the importance of scientifically proving that CAMS works has always been paramount. What we now know from clinical trial data is gratifying; in 6-8 sessions CAMS reliably shifts the patient’s perspective on suicide, creating a different way to think and feel about it, and experience life anew. The single biggest effect-size from the CAMS meta-analysis is the fact that CAMS significantly decreases hopelessness while significantly increasing hope (compared to control treatments). CAMS also reliably reduces overall symptom distress across clinical trials. In other words, CAMS does not necessarily eradicate every vestige of suicidality. Instead the data show that CAMS helps make the patient’s suicidal thoughts and feelings more manageable which makes them more behaviorally stable while it opens the door to consider life in a different way. When this occurs, it is a profound clinical achievement that clearly decreases suffering and can help save lives as well.

3rd Edition Highlights

Given all that has happened over the past 25 years, writing the 3rd edition has been a joy. I am delighted to have Thomas Joiner writing the foreword and it is a pleasure to report out what we now know about CAMS—how it works and what it does. The forthcoming SSF-5 has a few tweaks but much of it remains unchanged because of the extant empirical support it has garnered. One tweak is moving from an overall judgment of risk (mild, moderate, high) to a new clinical judgment related to concern about the patient’s relative stability (none, mild, moderate, serious, and extreme). There is a new Stabilization Support Plan (SSP) that can be used with significant others that complements the patient’s CAMS Stabilization Plan. There is further consideration of CAMS driver-oriented treatment planning and a major revision of the optional use of the CAMS Therapeutic Worksheet. There is further exploration of a “post-suicidal life” and a new optional Living Status Form (LSF) that completely mirrors the first page SSF used in the first session for successful CAMS outcomes. These are but a few highlights of the 3rd edition that includes an update of the clinical research literature, particularly the ever increasing CAMS-related studies.

Research is Hard, Expensive, & Endlessly Challenging

As I now reflect on the perspectives I have cultivated in writing the 3rd edition over the last year, a few observations surface. First, I am fortunate to have known Ed Shneidman, Bob Litman, Norm Farberow, and Jerry Motto—our founding fathers—who each influenced me deeply. The early support of Lanny Berman and giants in the field including Aaron Beck, Marsha Linehan, and Don Meichenbaum has been immeasurable. Second, there is nothing quite like clinical trial research. Studying a suicide-focused treatment is frankly harrowing; it is hard to do, expensive, risky, and endlessly challenging. Each study is a gamble; results do not always turn out as we would hope. Yet we always learn and find new ways to persevere based on what we find. And third, writing a series of books is a hell of a way to develop, support, and promote a new clinical intervention. Across three editions I have learned so much, and I have done my level best to translate that learning into helping patients who suffer and their providers who struggle to care.

The Cultivation of Wisdom

As I return to the classroom this fall, I will be heading into my final lap of my long academic run. Another seven years—one more blessed sabbatical—and then a transition into emeritus life and a well-earned retirement (God willing). Given the aches and pains, and various affronts of getting older, there are still certain virtues of becoming senior within our youth-obsessed culture. Among the virtues that rise to the top for me is: wisdom. In my view, wisdom is a remarkably underappreciated construct. In terms of perspective, wisdom is a pinnacle attainment within the pursuit of perspective-cultivation. Wisdom only comes with experience and the accrual of time; it is the operational culmination of an amassed perspective that is reflected in finely-tuning sound judgment. Wisdom is something that is best shared in a focused and measured way, always with a sense of patience and an experience-informed sense of timing. It often involves listening more and speaking less. But when words of wisdom are rendered, such words can carry the gravitas of a well-earned and valuable informed perspective. Simply stated, wisdom is cultivated perspective, par excellence! Having meaningful work, great love, and playing hard and well over the years all seem to contribute to an overall accumulation of experiential wealth that can directly inform one’s perspective and one’s sense of hard-earned wisdom. And apparently writing a few books along the way seems to help too! But for my part, with the time I have left, I will endeavor to listen more and speak less and endeavor to make my words count for the greater good.

Podcast: To Hospitalize or Not to Hospitalize, the Question Most Therapists Struggle with in Helping Clients with Suicidality

Episode Summary

In this interview, Dave discusses his career in researching suicide and how Marsha Lineman encouraged him to go beyond his assessment work to create an intervention for therapists working with clients who are suicidal. He discusses how many therapists struggle to know how to effectively assess suicide risk and intervene in a manner that can build the therapeutic relationship as well as keep clients safe. He explains that due to lack of training, knowledge of evidence-based interventions, and fear, therapists often jump to hospitalizing their clients, when it may not be necessary, and he challenges the overall utility and effectiveness of hospitalization altogether. Dave discusses his clinical tool and intervention, the Suicide Status Form (SSF-4) and his Collaborative Assessment and Management of Suicidality (CAMS), which have been found to decrease suicidal risk in patients through randomized controlled trials. He explains that therapists can effectively treat suicidality through collaboration, being clear and transparent on the limits of confidentiality and what may lead to a hospitalization. His intervention helps reduce access to lethal means as well as the value of identifying and treating patient-defined “drivers” for suicide, which research shows leads to decreasing hopelessness while increasing hope. The topics of suicidal ideation vs. suicidal intent are discussed and how ideation in itself is sometimes a form of coping. He speaks to the most feared situations where the therapist is not sure if the client can be sufficiently stable for outpatient care, and he addresses cases in which clients who take their life despite all clinical best efforts. Dave encourages therapists to become more competent in suicide assessment and treatment, because even though clinicians may screen for suicide when accepting patients, it is inevitable that they will have clients who are suicidal. He argues that suicide risk being “not something I work with,” is a problematic stance as it reflects an unwillingness to work with the one fatality of mental health.

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About David A. Jobes Ph.D. ABPP

David A. Jobes Ph.D. ABPP
David Jobes, PhD, ABPP, is the founder of CAMS-care, LLC. He began his career in 1987 in the Counseling Center of the Catholic University of America, where he developed a suicide risk assessment tool for college students that evolved into CAMS. Dr. Jobes is now a Professor of Psychology and Associate Director of Clinical Training at Catholic; he has trained thousands of mental health professionals in the United States and abroad in evidence-based assessment and treatment of suicide risk and the use of CAMS.

New Perspectives on Suicide Risk Among Military Personnel and Veterans

New Perspectives on Suicide Risk Among Military Personnel and Veterans On-Demand Webinar

Suicide rates among U.S. military personnel and military veterans remain elevated despite considerable investment in a wide range of suicide prevention strategies, befuddling researchers, clinicians, and military leaders. This presentation critiques traditional assumptions about the processes by which suicidal ideation and suicidal behaviors are interrelated, and reviews new empirical findings that cast a different perspective on the nature of suicidal ideation. Implications for clinical practice and suicide prevention among military personnel and veterans are discussed.

About Dr. Craig J. Bryan

Dr. Craig J. Bryan, PsyD, ABPP

Dr. Craig J. Bryan, PsyD, ABPP, is a board-certified clinical psychologist in cognitive behavioral psychology. He is the Stress, Trauma, and Resilience (STAR) Professor of Psychiatry and Behavioral Health at The Ohio State University Wexner Medical Center, and is the Division Director for Recovery and Resilience. Dr. Bryan received his PsyD in clinical psychology in 2006 from Baylor University and completed his clinical psychology residency at the Wilford Hall Medical Center, Lackland Air Force Base, TX. Dr. Bryan deployed to Balad, Iraq, in 2009, where he served as the Director of the Traumatic Brain Injury Clinic at the Air Force Theater Hospital. He separated from active duty service shortly after his deployment, and started researching PTSD, suicidal behaviors and suicide prevention strategies, and psychological health and resiliency. He has held faculty appointments at the University of Texas Health San Antonio, the University of Utah, and The Ohio State University Wexner Medical Center, and has managed numerous federally-funded projects in excess of $30 million focused on testing treatments for reducing suicidal behaviors, developing innovative methods to identify and detect high-risk individuals, and facilitating recovery after trauma. Dr. Bryan has published hundreds of peer-reviewed scientific articles. His research has been funded by a wide range of agencies including the Department of Defense, the National Institutes of Health, the Boeing Company, and the Bob Woodruff Foundation, and has been featured in media outlets including Scientific American, CNN, Fox News, NPR, USA Today, the LA Times, the New York Times, and the Washington Post. Dr. Bryan has published over 200 scientific articles and multiple books including Brief Cognitive Behavioral Therapy for Suicide Prevention and Rethinking Suicide.

Dr. Bryan has served as the lead risk management consultant for the $25 million STRONG STAR Research Consortium and the $45 million Consortium to Alleviate PTSD, which investigates treatments for combat-related PTSD among military personnel. Dr. Bryan has served on the Board of Directors of the American Association for Suicidology, the Scientific Advisory Board for the Navy SEAL Foundation, and the Educational Advisory Board of the National Center for PTSD. He has served as a consultant to the Department of Defense, Department of Veterans Affairs, Federal Bureau of Prisons, Avera Health, and Aurora Health Care. For his contributions to mental health and suicide prevention, Dr. Bryan has received numerous awards and recognitions including the Arthur W. Melton Award for Early Career Achievement, the Peter J.N. Linnerooth National Service Award, and the Charles S. Gersoni Military Psychology Award from the American Psychological Association; and the Edwin S Shneidman Award for outstanding contributions to research in suicide from the American Association of Suicidology. He is an internationally recognized expert on suicide prevention, trauma, and resilience.

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Telehealth: A Critical Tool for Treating Suicidal Risk On-Demand

Telehealth: A Critical Tool for Treating Suicidal Risk On-Demand Webinar

In this hour-long webinar, “Telehealth: A Critical Tool for Treating Suicidal Risk”. Dr. David Jobes, the creator of the Collaborative Assessment and Management of Suicidality, discusses the benefits of telehealth using evidenced based treatment. 15,000,000 adults and youth in the US struggle with serious thoughts of suicide. Thoughts matter and telehealth is a critical tool in working with this population.

Hosted by Dr. Kevin Crowley, clinical psychologist, private practitioner and CAMS Consultant.

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