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.

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.

When It is Darkest: Why People Die by Suicide On-Demand

When It is Darkest: Why People Die by Suicide: On-Demand Webinar

Based around his new book, Dr. Rory O’Connor will try to dispel myths around suicide. He will also describe the complex set of factors that can lead to suicide, drawing from the innovative Integrated Motivational-Volitional Model of Suicide. Dr. O’Connor will end with an overview of what we can do to support those who are vulnerable.

Dr. Rory O'Connor

About Dr. Rory O’Connor

Rory O’Connor PhD FAcSS is Professor of Health Psychology at the University of Glasgow in Scotland, President of the International Association for Suicide Prevention and a Past President of the International Academy of Suicide Research. Rory leads the Suicidal Behaviour Research Laboratory (Web: www.suicideresearch.info; Twitter: @suicideresearch) at Glasgow, one of the leading suicide/self-harm research groups in UK. He also leads the Mental Health & Wellbeing Research Group at Glasgow. He has published extensively in the field of suicide and self-harm, specifically concerning the psychological processes which precipitate suicidal behaviour and self-harm. He is also co-author/editor of several books and is author of When It is Darkest. Why People Die by Suicide and What We Can Do To Prevent It (2021). He is Co-Editor-in-Chief of Archives of Suicide Research and Associate Editor of Suicide and Life-Threatening Behavior. Rory acts as an advisor to a range of national and international organisations including national governments on the areas of suicide and self-harm. He is also Co-Chair of the Academic Advisory Group to the Scottish Government’s National Suicide Prevention Leadership Group.

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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!”

404 ERROR: Mistakes We Need to Stop Making in Suicidology On-Demand

Rates of death from heart disease, stroke, drunk driving, homicide, and other public health problems have fallen substantially. Yet, suicide deaths have not declined. Why is suicidology not doing better? In this webinar I suggest that we overvalue predicting suicide — so much so that we mistakenly treat prediction as synonymous with understanding and preventing suicide. In reality, highly accurate real-world prediction is a) neither sufficient nor necessary for suicide prevention, b) impossible to achieve, and c) an inappropriate basis for developing and validating suicide theory. These claims may sound counterintuitive, but they reflect common knowledge and practice in other fields of health and science. If we want to make progress, suicidology must correct these mistakes, and adjust suicide research and prevention efforts accordingly.

Dr. E. David Klonsky

About Dr. E. David Klonsky

E. David Klonsky, PhD, is Professor of Psychology at the University of British Columbia. He has more than 100 publications on suicide, self-injury, and related topics, and his contributions have been recognized by awards from the American Association of Suicidology, Association for Psychological Science, and Society of Clinical Psychology (APA). He is Past-President of the International Society for the Study of Self-injury, Associate Editor of Suicide and Life-Threatening Behavior, and has advised the American Psychiatric Association for DSM-5 and both the US and Canadian governments regarding suicide and self-injury prevention. In 2015 he published the Three-Step Theory (3ST) of suicide.

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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.

On-Demand: Providing Effective, Risk Managed Treatment for Potentially Suicidal Patients in Outpatient Private Practice

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CAMS-care has partnered with The Trust and TrustPARMA to offer this free webinar as a way for psychologists to build awareness about using an evidence-based, suicide-focused treatment for suicidal patients. Our experts will explore the issues psychologists face and how to address licensing boards and angry clients. They’ll also look at the prevalence of suicidal ideation and why training more clinicians in evidence-based treatment is paramount to reducing the national suicide rate.

They’ll detail the magnitude of suicide rates in America, screening and assessment best practices to determine when to hospitalize a suicidal patient and the considerations for treating patients in an outpatient clinical setting. There will be an overview of evidence-based treatments (DBT, CT-SP, BCBT, and CAMS), systems of care, why psychologists will continue to play a vital role, using the Suicide Status Form (SSF) as a clinical roadmap, and much more.

Dr. Eric A. Harris

About Dr. Eric A. Harris

Dr. Harris is a licensed psychologist and attorney in Massachusetts. Dr. Harris received his J.D. from Harvard Law School and his Ed.D. in Clinical Psychology and Public Practice from the Harvard University School of Education. He was the initiator of the Trust risk management program in 1994 and has provided risk management services to Trust Insured since then.

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.

Adolescent Suicide Prevention On-Demand

Dr. Cheryl King shares her extensive expertise on youth suicide prevention. Highlights of her presentation center on risk factors for youth suicide, screening, and assessment. In addition, Dr. King discusses clinical prevention work including her YST approach.

Dr. Cheryl King

About Dr. Cheryl King

Cheryl King, Ph.D., ABPP, is a Professor in the Departments of Psychiatry and Psychology and Director of the Youth Depression and Suicide Prevention Program at the University of Michigan. Her research focuses on the development of evidence-based practices for suicide risk screening, assessment, and intervention. She has provided leadership for multiple NIMH-funded projects, including Emergency Department Screen for Teens at Risk for Suicide, 24-Hour Risk for Suicide Attempts in a National Cohort of Adolescents, the Youth-Nominated Support Team Intervention for Suicidal Adolescents, and Electronic Bridge to Mental Health for College Students. A clinical psychologist, educator, and research mentor, Dr. King has served as Director of Psychology Training and Chief Psychologist in the Department of Psychiatry and has twice received the Teacher of the Year Award in Child and Adolescent Psychiatry. She is the lead author of Teen Suicide Risk: A Practitioner Guide to Screening, Assessment, and Management. In addition, Dr. King has provided testimony in the U.S. Senate on youth suicide prevention and is a Past President of the American Association of Suicidology, the Association of Psychologists in Academic Health Centers, and the Society for Clinical Child and Adolescent Psychology. She is a current member of the National Advisory Mental Health Council.

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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.