Category: Research

Big Ideas for Advancing Suicide Prevention

Posted on by erics

The recent end of the Spring 2023 semester marked my 40th year of working in the field of suicide prevention. During my first year in graduate school at American University, I took a remarkable class with Dr. Lanny Berman in the Spring of 1983. Lanny would soon become my major professor and the person who steered me into the world of suicidology. His course was entitled “Suicide, Death, and Life-Threatening Behavior,” and it was an eye-opening immersion into this important area of study. During that memorable semester, Lanny and I began a productive collaboration that led to my master’s thesis, my doctoral dissertation, many journal articles, book chapters, and a couple of books. Through my work with Lanny I had the good fortune to meet and work with many of the founders and heroes of the field, including Ed Shneidman, Bob Litman, Norman Farberow, Jerry Motto, and Marsha Linehan. Little did I know sitting in Lanny’s class all those years ago that my nascent interest in suicidology would evolve into a remarkably rewarding career that has been singularly dedicated to this important cause.

My Final Decade of Suicide Research

As I enter into my final decade of work in this field, I find myself at the ripe old age of 64 reflecting on the many challenges, abject failures, and dead ends that are inherent to the study of suicide. But through a lot of hard work, perseverance, and good fortune, there have been noteworthy successes. Chief among these has been the creation of CAMS and a rigorous line of clinical research to prove its effectiveness. And now with ten published open trials, seven published randomized controlled trials (RCTs), and two supportive meta-analyses, the question of whether CAMS works has been answered. The replicated and independent clinical trial data show that CAMS reliably reduces suicidal ideation (SI) and overall symptom distress, while it also consistently increases hope and decreases hopelessness. Of course, additional research questions still linger. For example, does CAMS reliably reduce suicide attempts and self-harm? And what exactly is the “secret sauce” of CAMS—the moderators, mediators, and mechanisms that make it work like it does? As for suicidal behaviors, I am delighted to note the publication of a new inpatient RCT of CAMS that was conducted in Germany showing that CAMS significantly reduced suicide attempts during the high-risk post-discharge period. Moderators, mediators, and mechanisms of CAMS are being further investigated within five ongoing RCTs of CAMS (and additional clinical trials of CAMS are now being developed). Building on this robust foundation of clinical evidence, our professional training company, CAMS-care, has trained thousands of clinicians across the nation and around the world. But from my perspective, perhaps the most exciting developments of all is the publication of the 3rd—and final—edition of the Guilford Press book, Managing Suicidal Risk: A Collaborative Approach. After two years of exhaustive work, this definitive source book on CAMS will prove to be a fitting capstone to the Guilford Press book series.

A Lack of Progress in Reducing Suicidal Suffering

While all these CAMS-related developments are exciting, I nevertheless find myself feeling frustrated and frankly impatient about the relative lack of progress overall within the larger field of suicidology. After 40 years of hammering away, I find myself craving more impactful changes and innovations to meaningfully reduce suicide-related suffering that can ultimately prevent this leading cause of death. So to this end, I would like to note and explore four particularly compelling big ideas that could make a meaningful impact as I further reflect on this field to which I have dedicated my professional life.

Focusing on Suicidal Ideation

Several years ago I found myself ruminating over the rejection of a manuscript from a peer review scientific journal. One particular reviewer pointedly dismissed various significant findings from a CAMS RCT because the intervention had failed to reduce suicide attempts. On the heels of this rejection, I began musing about the issue of “only” reducing suicidal ideation as a major criticism of CAMS. I then started to look at this critique differently. I began to question the behavioral bias that has dominated the field and I started to formulate an argument for the importance of suicidal ideation in and of itself. In fact, I have come to believe that reducing suicidal ideation may actually be a more important outcome vs. solely focusing on suicide attempt and self-harm behaviors. This train of thought was something that I had memorably discussed with my friend and colleague Dr. Thomas Joiner. I thus emailed Thomas and we ultimately wrote a well-received editorial entitled “Reflections on Suicidal Ideation” that was published in the journal Crisis—The Journal of Crisis Intervention and Suicide Prevention . In this piece, we argued that from a population perspective, that the biggest challenge we face in suicide prevention (by far) is the population of people who report “serious thoughts of suicide” in a given year. According to a recent SAMHSA (2022 ) survey, the population with serious SI included 15,600,000 American adults and adolescents in 2021 (the most recent year of data collection). Mind you, this number dwarfs the population that attempt suicide (1.7 adults in 2021) and is well over 300 times greater than the number of those who die by suicide. As Thomas thoughtfully noted, this is a profound level of human suffering. We argued that identifying and helping this enormous population upstream, could result in fewer attempts and suicides downstream. We consequently asserted that a shift in the field was needed to more fully appreciate and investigate the importance of SI as a means of decreasing this pervasive form of human suffering. Importantly, while there are excellent treatments that reduce suicidal behaviors (e.g., DBT, CT-SP, BCBT, and ASSIP) they do NOT reliably reduce suicidal ideation. Since this piece, we have endeavored to shift thinking within the field to meaningfully increase a focus on suicidal ideation within our collective research, clinical practices, prevention programming, and policy-related work.

Jaspr Health – Providing Hope during ED Visits

One summer day some years ago I was on a call with my colleagues Drs. Linda Dimeff and Kelly Koerner who were telling me about the successful use of an avatar named “Nurse Louis” and how this avatar-based technology demonstrated success related to discharge orders with medical surgical patients in a study conducted by Boston College investigators. The conversation evolved as we talked about the experiences of patients who are suicidal within emergency departments (ED) and I noted an extensive literature about how negative the ED experience can be for such people. This call became the genesis of a whole new avatar intervention that led to a NIMH-funded Small Business Innovation Research (SBIR) grant and the creation of an avatar based on my likeness named “Dr. Dave” that would be used to engage patients who were suicidal in the ED . Our novel tablet-based digital intervention integrated key elements of CAMS (among other related interventions from DBT and elsewhere). The striking initial success of this intervention was also in part due to the input of people with lived experience (of having been suicidal) which led to the integration of this important voice in developing the application and in the form of video testimonial stories of recovery and hope. Further NIMH SBIR funding led to an evolved intervention named “Jaspr Health” which was further shaped and refined based on input from a panel of people with lived experiences (and Dr. Dave was “retired” to my relief). Even though our RCT of Jaspr was cut short by EDs being overrun by Covid-19 patients, the obvious success within our underpowered clinical trial nevertheless provided ample and convincing evidence of the effectiveness of this novel intervention . Importantly, across my travels I have never heard of any ED experiences for patients who are suicidal being characterized as positive—not in the US, China, Uruguay, Australia, or throughout Europe. And yet with Jaspr, patients in the ED were having notably positive experiences and their Jaspr “favorites” could be downloaded to their smart phone for later use. Doctors get full reports based on CAMS aspects of the app which also ensures that certain Joint Commission institutional requirements are met as well. This remarkable line of innovation and clinical research is ongoing and reflects a fresh and exciting solution for a particularly infamous worldwide need—providing effective suicide-focused care in emergency departments for those patients who struggle with suicidal thoughts and behaviors.

The Hope Institute – Keeping Suicidal Patients out of the Hospital

Another undeniably compelling and recent development in suicide-focused clinical care is The Hope Institute that has been developed by my colleague Derek Lee in Perrysburg Ohio. The Hope Institute is an outpatient crisis setting that employs the use of both CAMS and DBT to stabilize patients who are suicidal using next day appointments (NDAs) and frequent visits (up to four times/week in some cases) to reliably stabilize patients in 5-7 weeks. The key within this model is that all care is suicide-focused and fundamentally evidence-based with proven clinical interventions. Perhaps most importantly, The Hope Institute singularly aspires to achieve stabilization as a worthy and valuable clinical goal in and of itself. Staff morale is high as clinicians do remarkable life-saving work. We are now in the process of standing up additional Hope Institutes in multiple different locations. The field needs this kind of model that emphasizes evidence-based, least-restrictive, cost-effective, suicide-focused clinical care to help people who struggle so that they can become stable and able to manage their suicidal thoughts, feelings, and behaviors. In my view, The Hope Institute is proving to be an exciting and notable clinical game-changer.

Mental Health Service Corp

Finally, I have been preoccupied with the idea of a “Mental Health Service Corp” since 2016. Given that 15.6M Americans wrestle with serious thoughts of suicide, we will frankly never have a sufficiently large and trained clinical workforce to begin to deal with the obvious and pressing needs of this considerable population (and research shows that many in this group do not want conventional mental health care). Given these considerations, a Mental Health Service Corp reflects one of my favorite pie in the sky big ideas that could significantly change the field. To have a Peace Corp-level national initiative to create a substantial paraprofessional workforce that could person the 988 Suicide & Crisis Lifeline, provide peer-support, work at respite and retreat centers for suicide stabilization, and with proper training and supervision even provide various evidence-based resources (e.g., safety planning, lethal means safety, and caring contacts) could have a profound impact. This concept was potentially under consideration by team members of the losing 2016 Presidential candidate. And while the concept did not play out then, it is nevertheless a compelling big idea that could be transformative if the political stars and will of the people were ever to align to make a significant difference in the larger suicide prevention workforce.

* * * * *

So, after 40 years, these are some of the big ideas to which I am drawn. I believe these ideas could make a meaningful difference for those who struggle in the most profound manner possible—considering suicide as an alternative to suffering. While progress is clearly being made, I am impatient. Far too many people continue to suffer, and too many people get hospitalized and medicated in ways that may not be helpful and might in fact be harmful. If we aspire to make a lifesaving difference, we must endeavor to think outside the box and fully embrace compelling big ideas to advance the field of suicide prevention.

A Voice of Autistic Adulthood: Suicide & Other Challenges Amongst Autistic Adults

Posted on by erics

Disclaimer: In this article, I use identity-first language when referring to autism rather than person-first language (autistic person vs person with autism). In the adult autistic community, we use this language because 1) being autistic is a part of our identity, and 2)autism is not a disorder. For more information about terminology check out this article on identity-first language by the Autism Network: https://autisticadvocacy.org/about-asan/identity-first-language/

Think of the word: autism. What image comes to mind? How would you describe an autistic person? Would you say they’re socially awkward, low empathy, genius, or weird? Or maybe you imagine an awkward, pompous nerd – one who unintentionally says the most inappropriate things, but means well. Like Sheldon from ‘The Big Bang Theory’ or Dr. Shaun Murphy from ‘The Good Doctor’. This stereotype of the autistic person is reductive, exaggerated, and harmful to the diversity and complexities of the adult autistic community.

This characterization was originally invented during WWII, when a Nazi eugenicist named Hans Asperger identified a subset of characteristics that explained the symptomatology of research subjects.[1] He began his experimentation on ‘undesirables’ or disabled children. Asperger discovered a subset of disabled boys who presented as antisocial and ‘lacking empathy’, but having advanced intellectual capabilities. These children were used as the perfect subjects for his discovery of Asperger’s Syndrome, and those who did not fit into his characterization were euthanized.[2]  The term and diagnosis of Aspergers is no longer used within the DSM-5-TR (and Aspergers has been integrated into the autistic diagnosis). However, the characterization of autism as a ‘genius’ disorder that only affects white boys has persisted and gained popularity since the 90’s. While some autistics are white, male geniuses, it is not the whole spectrum of our identities. We represent the collective diversity that is present in the world. In fact, a vast majority of autistic individuals identify as LGBTQ, are women and/or non-binary.[3] Some of us are a part of the High IQ society, while others struggle with math. Some of us love trains, while others are obsessed with lining up their barbie dolls or are die-hard thespians. Autistic people come in a variety of identities, and to limit these complexities, hinders the assessment, support, and resources we receive as adults. In this article, we will examine the challenges autistic adults experience and the types of support adult autistic individuals need to improve functionality.

 What is autism?

  • Autism or Autism Spectrum Disorder (ASD) is a neuro-developmental condition that impacts the way a person communicates, perceives, and interacts with the world around them.[4] Autistic traits include the below, though there are numerous other tendencies that can be described as autistic lack of eye contact
  • an interest in select special interest
  • (repetitive, reflexive movements used to self-regulate or express joy; E.g. arm flapping or humming)
  • Following rigid routines
  • Prone to meltdowns and over stimulation
  • Difficulty understand subtext in communication (takes things literally)

Autism is not a mental health disorder nor a disease; although mental disorders and physical disabilities d co-occur.[5] In a more simplistic terms, autism is a different way of functioning and perceiving the world. For non-autistics (or neurotypical individuals), autistic people are perceived as ignoring social norms, lacking social competency, and communicative skills. However, to us, our functioning is a normal way we interact with the world. From our perspective, we adhere to our moral compass, communicate directly, and our intentions are genuine. Autistics are not asking to be fixed. They are asking for understanding, support, and resources to improve their functionality in a world that is not designed for them. Without these supportive systems, autistic adults face a multitude of challenges that lead towards factors of trauma, alienation, and abuse.

5 Common Challenges Faced by Autistic Adults

  1. Substance Addiction.

    Research suggests that 50% of autistic adults develop substance addiction within their lifetime.[6] Drugs, alcohol, and other substances both alter behavioral responses and coping mechanisms. From one angle, substances can be a barrier against the anxieties of strenuous, social interactions. An autistic adult who is perceived as ‘socially awkward’ and ‘withdrawn’ while sober, may become the life of the party (or at least socially ‘normal’) while in an altered state. This allows the person to mask—a coping mechanism for autistic people where they interact with others using neurotypical behaviors. From another angle, substances are also a coping mechanism in helping autistic adults deal with the long-term effects of bullying, trauma, and loneliness.

  2. Suicidality & Shorter Life Expectancy

    Death by suicide is three times higher in autistic adults than in the general population.[7] For autistic women the rates of suicidal behavior and non-suicidal self-harm is even higher. [8] As previously discussed, Autistic adults have a lifetime of experiences with childhood bullying, which leads to adult trauma. These traumas are often comorbid with anxiety, depression, post traumatic stress disorder (PTSD), and complex post-traumatic stress disorder (C-PTSD). [9] As the NIH research shows, these co-occurring with psychological disorders increases an autistic adult’s risk of suicidal ideation. Individuals experiencing comorbid anxiety disorders in tandem with autism will often experience higher suicidal risk, and be more susceptible to its effects

    Autistic adults have lower life expectancy in comparison to the general population.[10] The average age expectancy for an autistic adult is 36 years. What’s causing these premature deaths? A few risk factors leading to premature deaths in autistic adults are linked to systemic discrimination, chronic disabilities, and economic challenges. We are more likely to be unemployed and live below the poverty line. In fact, over 60% of autistic adults are unemployed.[11] Circumstances that are impacted by employment consist of hardships within the job application, interview, and hiring process. In addition, we are more likely to have chronic disabilities, such as autoimmune disorders, chronic inflammation (which can lead to cancer), and other health problems that are linked to lower life expectancy. [12]

  3. Childhood Bullying & Abusive Adult Relationships

    Over 60% of autistic children and teens experience bullying. [13] The long term effects of bullying include, but are not limited to: low self-esteem, trust issues, social isolation, relational problems, depression, and anxiety. These long term effects continue into adulthood.

    As adults, many autistic individuals (especially women) experience abusive intimate partner relationships. An alarming study conducted in 2022, found that 9 out of 10 autistic women experienced sexual assault. [14] Many abusers prey on individuals who are disabled, and autistic people are an easy target due to our neurological wiring and alienation. Autistic adults tend to be more trusting of people and may not recognize red flags/toxic behavior, due to a history of trauma and people-pleasing tendencies.

  4. Misdiagnosis.

    Within the autistic community and neurodivergent-affirming therapeutic spaces, self-diagnosis as autistic is valid. For autistics within underserved communities (i.e., BIPOC, LGBTQ, women, etc…) official and early diagnosis has been inaccessible, unaffordable, and misdiagnosed. Autistic individuals have been misdiagnosed with mental disorders such as bipolar disorder, borderline personality disorder, schizophrenia, antisocial personality disorder, and other mental health functionalities.[15] As discussed earlier, autistic behaviors present differently within each individual and sometimes behaviors are similar or co-occur with diagnostic criteria of mental disorders. Sometimes autistic behaviors are overlooked by family members or providers based on societal biases. For example, autistic behaviors in boys are often categorized by ‘antisocial’ or withdrawn behavior. However, many young girls and women are socialized to be more socially adaptable and are ‘better” at masking autistic traits. For many marginalized groups, masking is a normalized response to systemic disparities.[16]

  5. Lack of Adult Resources & Support.

    ASD is officially diagnosed in childhood through a lengthy evaluation process, which contains parent/teacher interviews, psychological assessments, and clinical observations. There are no adult assessments, so assessments are based on the same criteria as the children’s assessments. Many of my autistic clients have shared, they find the assessment process to be intrusive and alienating. Those who are estranged from their bio families, have difficulties with the parent interview process. Diagnostic rates range from $1,000 and up, which eliminates individuals with low socioeconomic status.

Once diagnosed, adult autistics are left without support in understanding their diagnosis, finding community, or navigating their daily lives. As with childhood diagnoses, often the only referral service is Applied Behavioral Analysis (ABA) therapy. For  adult advocates, community members, and professionals (like myself) ABA is an abusive treatment practice. Founded by the misguided creator of gay conversion therapy, ABA is a treatment that uses extreme compliance and erasure of autistic autonomy, enforcing normative behavior by repressing ‘undesirable’ autistic traits (i.e. stimming, natural coping strategies for overstimulation, etc…).[17] For example, a child who is lashing out by screaming and hitting themselves is perceived as destructive. In ABA, the why is not addressed. A course of negative reinforcement, by way of restricting stimming (self-soothing, autistic behaviors) and the autistic child’s favorite things is the treatment.  Eventually the child stops the destructive behavior and everyone moves on. Except, the basis for the meltdown continues and the child internalizes their autistic traits. If we deconstruct the autistic child’s behavior from a neurodivergent affirming framework, our treatment plan centers the child’s needs, autonomy, and self-confidence. Autistic adults who had ABA therapy as children self-reported and current research studies show the long-term effects of ABA include increased depression, anxiety, and PTSD symptoms.[18]

[When an autistic child is experiencing sensory overload, they experience meltdowns that include hitting themselves, biting, screaming, and other non-verbal behaviors. This behavior is called an autistic meltdown and the best approach to stopping the behavior, is to remove the child from the stimulant. As a child, I would often become overstimulated by overhead lights or intense sounds (family gatherings). I could not articulate what I was experiencing and would fall into meltdowns of epic proportions. As a late-diagnosed adult, I can finally comprehend that I am overstimulated and take measures to reduce my discomfort. Noise-cancelling headphones or temporarily moving to a quiet area has increased my autonomy and interpersonal relationships. However, for a child (especially non-verbal, autistic children) communicating these discomforts is impossible and is often punished rather than supported.]

A Modified-CAMS Autistic Approach

The Collaborative Assessment and Management of Suicidality (CAMS) is an evidence-based therapeutic approach using randomized control trials as an effective approach to decreasing suicidal risk across a diverse range of clients.[19] We autistic individuals tend to love concise, clear, and organized information. In my professional opinion, the effectiveness of CAMS in articulating direct questions and organization through the Suicide Status Form (SSF), makes CAMS an effective framework to support autistic teens and adults. Below, I have compiled a list of 3 ways CAMS can be modified to directly support autistic individuals. [These suggestions can also be applied to general therapeutic practices].

  1. Use a Direct, Concise Approach

    . As I have discussed, autistic people oftten need concise, direct language when communicating. It is imperative for the provider to use direct language, due to the communication barriers that are frequently presented in conversations between neurotypical and autistics. For example, when a neurotypical question such as “how are you feeling?” is asked, a neurotypical person might say, “I’m feeling sad”. For many autistic people this question is not direct because it can be applied to a number of factors (I.e., how I’m feeling in the present moment, or how I’m feeling regarding interacting with you, or even how I’m feeling regarding the weather). Another factor to consider is that some autistics have alexithymia—an inability to identify and describe emotions. Often when asked about emotional states an autistic person might respond by saying “I don’t know” or even state an emotion that is opposite of what they are feeling. When filling out the SFS with the client, ask questions that are concise, but also describe what you mean, such as, “when you think about dying by suicide, where in the body do you feel it?” or “do you have a plan to die by suicide?”.

  2. Be Open to Unconventional Support Systems.

    For many autistic , making and maintaining relationships is extremely difficult – and adult relationships especially. In addition to communication difficulties, factors such as emotional dysregulation and rejection sensitivity makes interpersonal relationships almost impossible. Due to a history of trauma, it can be hard for autistic individuals to reach out for support. Even greater, due to limited resources, support can be inaccessible. When discussing external support systems with a client, providers must ‘think outside the box’. This may look like finding external support through adult autistic online communities, support groups, or social media spaces. Or creating a support plan that includes non-family systems such as friends, neighbors, and fellow providers.

  3. Respect Their Autonomy.

    If I gained a quarter for every time someone spoke to me as if I was a child or incapable of making decisions, after disclosing I’m autistic to a provider, well I could retire. The spectrum of functionality of autistic people is so broad, that one autistic adult might have challenges with motor skills (dyspraxia), while another has difficulty with word processing (dyslexia). No two autistic individuals are similar and we are not a monolith. To support autistic clients is to 1) trust they are the expert on their own experience and 2) functionality difficulties are different in each individual.

 

Finding support for autistic adults is universally inaccessible to many underserved communities. Many medical and mental health providers are not versed in providing evidence-based, neurodivergent-affirming treatment. They do not receive training on recognizing autistic traits nor how to interact with autistic adults. It makes seeking medical and mental health support problematic. Navigating the challenges of dating, sex, employment, and all the other complexities of adulthood becomes an impossible reality for unsupported autistic adults. Which leads to increased burnout, meltdowns, and mental health tragedies.

References

[1] Neurotribes: The Legacy of Autism and the Future of Neurodiversity by Steve Silberman

[2] https://www.nytimes.com/2018/03/31/opinion/sunday/nazi-history-asperger.html

[3] https://www.cam.ac.uk/research/news/autistic-individuals-are-more-likely-to-be-lgbtq

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6225088/

[5] https://www.theatlantic.com/health/archive/2017/03/autism-and-addiction/518289/

[6] https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774847

[7] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457664/

[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6225088/

[9] https://www.cnn.com/2017/03/21/health/autism-injury-deaths-study/index.html

[10] https://drexel.edu/~/media/Files/autismoutcomes/publications/LCO Fact Sheet Employment.ashx

[11] https://www.cam.ac.uk/research/news/autistic-adults-have-a-higher-rate-of-physical-health-conditions

[12] https://www.cbsnews.com/news/survey-finds-63-of-children-with-autism-bullied/

[13] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9087551/

[14] https://www.cambridge.org/core/journals/cns-spectrums/article/what-misdiagnoses-do-women-with-autism-spectrum-disorder-receive-in-the-dsm5/37409014E08A16D93FF0DB95675E9EED

[15] https://www.aane.org/women-asperger-profiles/

[16] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9114057/

[17] https://neuroclastic.com/invisible-abuse-aba-and-the-things-only-autistic-people-can-see/

[18] https://cams-care.com/about-cams/the-evidence-base-for-cams/

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.

The NEED for Competence and Confidence

Posted on by erics

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hope

Posted on by erics

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

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

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

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

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

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

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

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

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

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

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

Considering Suicidal Ideation—Again!

Posted on by erics

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

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

Serious Thoughts of Suicide Graph

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

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

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

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

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

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

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

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

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

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

Posted on by erics

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

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

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

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

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

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

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

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

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

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

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

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

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

Posted on by erics

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

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

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

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

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

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

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

Cams-care Image

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

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

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

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

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

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