Category: Systems of Care

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/

10 Tips for Using CAMS with Adherence

Posted on by erics

For a proven intervention to be effective in the field, clinicians must use the intervention with adherence, meaning it is used as designed, based on extensive support from clinical trial research. Clinical adherence challenges are particularly prominent when conducting a randomized controlled trial (RCT)—which is the gold standard methodology for proving an intervention is effective.

The Importance of Adherence in Randomized Controlled Trials

Within RCTs, researchers must ensure that an experimental treatment is reliably provided with adherence and that there is fidelity between experimental treatment arms (i.e., that in fact the targeted treatment and control treatment were administered as intended). There are currently six published and four active CAMS RCTs — three funded by the National Institute of Mental Health and a fourth funded by Veterans Affairs.

Across these RCTs, members of The Catholic University Suicide Prevention Laboratory (SPL) that I direct take the lead in training CAMS to RCT study providers. In turn, we are also responsible for watching digital recordings (on secure platforms) of clinicians endeavoring to provide CAMS with adherence with patients who are suicidal.

The Role of Adherence Feedback in RCTs

To do this with scientific rigor, we use two expert SPL coders rating each session using the CAMS Rating Scale (CRS) with high inter-rater reliability. In addition, SPL graduate students also watch comparison control sessions (e.g., clinicians providing “treatment as usual”—TAU) to ensure that these clinicians are doing the comparison control treatment—and not doing CAMS—confirming experimental fidelity.

To this end, over the fall semester of 2022, the SPL has been working hard to support the three NIMH-funded CAMS RCTs which means beyond the initial CAMS trainings that I lead, we all watch a lot of digital recordings of clinicians working diligently to provide CAMS with adherence.

This means SPL members watch dozens of sessions each week. I personally watched 15 recordings over the past few weeks. It’s a busy time for members of the SPL supporting providers across three RCTs to fully meet our criteria for adherence to CAMS. Once study providers are determined to be adherent, our workload decreases significantly as we do random spot checks to confirm that clinicians do not fall out of adherence (which can require training remediation work with providers if this occurs).

10 Tips for Becoming Adherent to CAMS

With this immersion of training and adherence it is inevitable that we encounter common challenges when providers are learning to use CAMS. With a bit of constructive CRS feedback and consultation coaching with our teams of providers, many of these issues quickly become a one-trial learning experience. Moreover, other providers on our consultation calls benefit from hearing about our constructive adherence feedback with their colleagues.

Within a matter of weeks, we usually get most of our clinical providers to meet adherence criteria to effectively provide CAMS. I would note that learning to use CAMS is not as challenging as learning other proven approaches in mental health. Dialectical Behavior Therapy, for example requires labor intensive training that may take months to achieve. But while CAMS is typically learned in fairly short order, there are still common mistakes when first using CAMS that can delay achieving adherence to the framework.

This blog is intended to help other beginning CAMS providers avoid some mistakes that we see among clinicians learning this model. Based on this adherence work let us thus consider 10 of the best tips for becoming adherent to CAMS.

Watch the Video Series 

1. Dive Right into CAMS

We often see a hesitancy on the provider’s part to dive right into using the Suicide Status Form (SSF) at the start of each session, especially with clinicians unfamiliar with CAMS. From the first session through interim care, there is too often unnecessary small talk or avoidance of starting into the SSF assessment using up valuable session time (particularly in the labor-intensive first meeting). The feedback we get is that clinicians feel that they have to form some sort of relationship with the patient before they can broach the sensitive topic of suicide. However, our extensive clinical trial research and one meta-analysis show that patients welcome SSF engagement getting to the heart of their struggle with suicide.

Indeed, when clinicians experience the patient feeling validated and understood by the SSF assessment, the temptation to avoid getting into the SSF assessment at the start of each session of CAMS quickly dissipates. Bottom line, suicide is serious business and there is no need for chit-chat at the start of each session of CAMS—let’s get down to business!

2. Interact During Suicide Status Form Core Assessment

The SSF Core Assessment is used at the start of every session of CAMS. Too often we see the clinician have the patient complete their SSF ratings of pain, stress, agitation, hopelessness, self-hate, and overall risk of suicide in silence. Using this approach, providers then typically review patient’s ratings and have some observations or some comments after the ratings are made.

In contrast, the completion of the SSF Core Assessment ratings offers a superb opportunity to discuss the patient’s ratings as they complete each SSF rating scale. This approach creates more of an ongoing dialogue about the ups and downs of suicidality and underscores the importance of candid and collaborative discussion of what the patient is experiencing as they complete these ratings.

3. First Session—Focus on Reasons for Dying (Instead of Reasons for Living)

Ever since I created the Reasons for Living (RFL) versus the Reasons for Dying (RFD) assessment as a major focus in the first session of CAMS, I have observed that clinicians often enthusiastically focus on the patient’s RFL responses. Understandably clinicians focus on RFLs as potential protective factors that might mitigate the patient’s suicide risk. However, based on two studies that we did with a large clinical trial sample in Switzerland, I have now come to see RFLs as a clinician assessment because patients we have studied are actually more focused on their RFDs in their first session!

When I train the model I therefore discourage RFL “cheerleading” because for some patients emphasizing their RFLs can invalidate their current struggle. At its worst, pushing RFLs can even be shaming! It is not uncommon to see inexperienced CAMS clinicians pointing out possible RFLs that the patient has not spontaneously generated — “What about your kids?” or “Isn’t your wonderful wife a reason to live?” Given the clinical trial research findings, we do not want clinicians pointing out RFLs that the patient has not listed.

For example, perhaps a patient sincerely believes they are a burden to their kids or their spouse and that their death may actually be a “gift” to these people. Denying this perspective prematurely can be dismissive of something that the patient may feel deeply. However, within CAMS we absolutely do emphasize RFLs, but we wait to do it later in the course of care when potential clinical progress has been made and the patient is more open to such considerations. Remember, the capstone of successful CAMS-guided care is a focus on the pursuit of a life that the patient actually wants to live. But to push a RFL agenda prematurely risks overriding the patient’s experience and may invalidate what they are going through at the start of care.

4. First Session—Move on Through Section B

Within the first session of CAMS, providers often get bogged down in Section B (which should take only 10 minutes) at the expense of completing the CAMS Stabilization Plan (CSP) and the CAMS Treatment® Plan. We advise in the RCTs that if a first session provider is falling behind, Section B does not need to be fully completed (as it can be completed later). That said, within Section B, it helps to get through the patient’s suicide attempt history, but then move on to the CAMS Treatment Plan focusing on the CSP and the two problem drivers in the remaining time.

5. First Session—CAMS Treatment Planning Always Begins with the CAMS Stabilization Plan

A huge error that even experienced CAMS providers make in the first session, is addressing Problems 2 and 3 before completing the CAMS Stabilization Plan! For adherence to the proven model, the CSP is always addressed first, then Problems 2 and 3 are completed as the final steps at the end of the first session of CAMS.

The reason that the CSP is the first step in the CAMS Treatment Plan is that establishing a sound CSP is the foundation for the entire treatment plan. An ability to satisfactorily complete the CSP may be an indication of imminent danger that might warrant an inpatient admission. However, if we can establish a solid CSP then the goal of CAMS to keep someone out of the hospital can be realized as we then shift the focus to problems/drivers that are usually quite treatable.

6. Have the Patient Identify Their Own Drivers for Suicide

Beyond the initial establishment of the CSP, all CAMS Treatment planning should center on the patient’s identification of their problem/drivers for suicide. In other words, the clinician should not point out the patient’s problem/drivers for them. In turn, the clinician should help the patient identify treatment goals and objectives before taking the lead identifying the full spectrum of interventions to address each respective problem/driver.

Ideally, we like to have more than one intervention for any one problem/driver of suicide. The more interventions we have to offer, the more hope we instill in the patient. Bottom line, the message to the patient is that there are many potential ways for effectively addressing the issues that compel the patient to consider suicide as a solution for their struggles.

7. Interim Sessions—CAMS Treatment Focuses on Crafting the Stabilization Plan and the Patient’s Suicidal Drivers

Across CAMS-guided interim care, all sessions begin promptly with Section A, the SSF Core Assessment. There should then be a check-in about the previous week in terms of the presence of suicidal thoughts, feelings, and behaviors. The clinician should always ask about the CSP sometime during the course of each interim session (often at the start but it can be at the end as well). The focus of all CAMS interim care centers on patient’s problems/drivers and possible updates or revisions to the CSP.

8. Interim Sessions—Treatment Plan Updating

Across CAMS-guided interim care, every session ends with updating the CAMS Treatment Plan. The treatment plan update should be done from scratch and potentially change in each interim session depending on what is happening in the course of care. But too often inexperienced clinicians complete Section A and Section B at the start of the session.
Section A should always be completed at the start of each interim session and Section B at the end of each interim session of CAMS. Moreover, we know from our clinical trial research that CAMS Treatment Plans that change across clinical care lead to better outcomes (in contrast to CAMS Treatment Plans that basically do not change from session to session).

9. You Can Delay Resolving CAMS if Needed

A patient may continue to be engaged in CAMS even when CAMS resolution criteria are technically met. To clarify, just because criteria are met, does not mean that you must necessarily move to the outcome-disposition session. Sometimes deferring the final session can help reassure both members of the clinical dyad that the patient’s apparent recovery is holding up and feels well-established.

10. Emphasize the Goal of Managing Suicidal Thoughts and Feelings to Achieve Behavioral Stability

As a clinical intervention, CAMS can be resolved even when some suicidal thoughts are present. In other words, the treatment difference that CAMS often enables a patient to better and more reliably manage suicidal thoughts and feelings while achieving behavioral stability.

From clinical trial research, we know that CAMS reliably increases hope while reducing hopelessness and overall symptom distress (i.e., general misery and despair). We thus know that CAMS significantly reduces suicide-related suffering and in so doing it can open the door to hope and the pursuit of life that the patient wants to live.
How to Use CAMS in a Clinical Setting

Working with patients who are suicidal is invariably challenging and can be daunting. Frankly, far too many clinicians endeavor to simply avoid such patients. Given this, we in the CatholicU SPL are humbled by and grateful to the clinicians across clinical trials who aspire to use CAMS with adherence.

Imagine having your clinical works viewed and rated with patients that many providers seek to avoid. It is not easy. It requires being open to constructive feedback and inevitable tweaks and suggestions to help one master CAMS. As clinicians in our trials courageously work to learn the intervention, members of the SPL do everything we can to be positive, supportive, validating, and reassuring as we give our constructive CRS feedback. In truth, we deeply admire these providers and clinical trials of CAMS could not be conducted without them. Consequently, the adherence work that we do inspires constructive tips like the ones described in this blog to help other providers achieve adherence to the framework.

The adherence work we do is challenging but worth it. Seeing clinicians quickly master the intervention is incredibly rewarding. When we provide thoughtful guidance on common mistake and provide instructive tips, we will have done our part in helping providers deliver a potentially life-saving course of care that has been proven to decrease suicidal suffering and overall misery. In turn, each RCT we publish increases the evidence base which we hope will may inspire more providers to learn and master this proven suicide-focused clinical intervention.

Learn more about how you can get started with CAMS Training and Certification to help identify suicidal drivers in patients in as little as six sessions.

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.

988 and the State of Suicide Treatment in the US

Posted on by erics

On July 16, 2022, the United States took an enormous step forward in crisis care and suicide prevention with the launch of a nationwide 3-digit, 24/7 helpline, known as “988.”

In parallel with 911, the FCC designation of this easy-to-remember number for the Suicide & Crisis Lifeline (formerly the National Suicide Prevention Lifeline), marks an important shift in the way that suicidal thoughts and actions are prioritized, identified, and treated in the United States. And it’s already revolutionizing how individuals living with suicidal thoughts connect to life-saving resources across the US.

But it’s not enough.

The State of Suicide Treatment & Prevention in the US

In 2020, the CDC reported over 312,000 emergency visits for “self-harm injuries” and 45,979 suicide deaths, making suicide the 12th leading cause of death in the US. Suicide was the third leading cause of death for Americans ages 10-24 and the 12th leading cause of death overall.

There are 12.2 million adults and 3 million adolescents in the US with serious thoughts of suicide and yet current wait times for behavioral health care and the treatment of suicidal thoughts can be months. And unfortunately, the launch of 988 will not alleviate this crisis of care on its own.

According to the HHS Assistant Secretary for Mental Health and Substance Use, and leader of the Substance Abuse and Mental Health Services Administration (SAMHSA), Miriam E. Delphin-Rittmon, Ph.D., the demand for timely, effective mental health and suicide interventions is only going to increase — even as federal investment reaches an all-time high.

“Recent investments made in the [988] Lifeline have already resulted in more calls, chats, and texts answered even as volume has increased, but we know that too many people are still experiencing suicidal crisis or mental health-related distress without the support they need.”

In 2021, the National Suicide Prevention Lifeline received 3.6 million calls, chats, and texts. SAMHSA expects that number to at least double within the first full year after the 988 transition.  According to Vibrant Emotional Health, call volumes to 988 are up 45% compared to the week before 988 went live and 66% compared to the same time in 2021.

How to Improve Suicide Treatment & Prevention at Scale

Creating an easy-to-use nationwide suicide prevention helpline is a fantastic tool that is already making a tangible impact on Americans’ lives. But 988 is just the first step in solving our national suicide crisis.

Suicide prevention and mental health crisis services will continue to overwhelm existing systems until we do these two things:

  1. Integrate evidence-based suicide treatment methods directly into the electronic health record (EHR) via the Suicide Status Form (SSF) so that every clinician has access to a simple, effective tool to assess and treat suicidal thoughts in a growing client population.
  2. Provide next-day suicide interventions across the country, regardless of location, with help from organizations like The Hope Institute.

Here’s how healthcare providers can build on the momentum of the 988 launch to create a better suicide response system and take the next steps in suicide treatment and prevention in the US.

Improving the Electronic Health Record with Evidence-Based Care

The biggest hurdle for effective suicide treatment and prevention in the US isn’t a lack of effective treatment models. In fact, the Collaborative Assessment and Management of Suicidality (CAMS) is one of four evidence-based treatments that are trusted by the Joint Commission, Surgeon General and the CDC.

CAMS itself 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.

So if the problem with suicide prevention isn’t a lack of effective treatment methods, what is the issue?

One of the biggest limiting factors in the US for improving suicide crisis care is the current Electronic Health Record (EHR) — or more accurately, the lack of evidence-based methods for suicidal treatment and prevention within most EHRs.

However, CAMS can change that with an 8-page form — the Suicide Status Form — that is a proven and reliable multi-purpose clinical tool once it’s included in the medical record.

How the SSF works

Simply put, the SSF functions as a clinical roadmap within CAMS for assessments, treatment planning, tracking ongoing risk, and clinical outcomes for suicidal ideation. It does this in three-parts:

1. Initial session (Pages 1-4)

The first session of CAMS includes a therapeutic assessment completed by the client and the clinician, and the development of a stabilization and a treatment plan for two “drivers” that the client says makes them consider suicide.

2. Interim (Pages 5 & 6)

In each interim session of CAMS, the clinician treats the client’s drivers and checks with the client to ensure the stabilization plan and treatment plan are working.

3. Outcome (Pages 7 & 8)

The final session of CAMS is held when the clinician and the client is behaviorally stable and able to manage suicidal thoughts and feelings.

Learn how to use the Suicide Status Form.

The goal is to build the Suicide Status Form directly into the medical record itself, integrating this effective method into the diagnosis, treatment, and even the billing model for clients across the country for continuity of care no matter where you are. Meta analytic research has even shown that collaboratively completing the assessment portions of the SSF is a therapeutic experience for the client in itself.

One substantial obstacle to the adoption of this evidence-based treatment has been the lack of adoption of this tool into EHRs.

Fortunately, that’s changing as more healthcare record providers recognize the need for integrated systems that streamline assessments, guide treatment, and improve client outcomes within increasing client populations — especially at scale.

Who is currently using the SSF?

At CAMS-care we are proud to say that we have partnered with several healthcare leaders to include the SSF in their platforms and client records including:

  • Epic
  • Netsmart
  • InSync
  • Psyquel
  • Bhworks – a School Mental Health Management System
  • NeuroFlow – a leading Health Integration Solution

These Electronic Health Record and Health Management platforms recognize that having access to evidence-based care within clients’ records is essential for clinicians to meet the complex needs of growing client populations. And that need is quickly being felt as 988 rolls out across the country.

The first crucial step in improving suicide outcomes is to integrate an evidence-based framework — like CAMS and the Suicide Status Form (SSF) — directly into the electronic health record so that every clinician has access to tools backed by more than 30 years of clinical trial evidence.

The next step is changing the way we respond to suicide crises by providing interventions as quickly as possible — ideally within 24 hours of first contact.

The Importance of Next-Day Suicide Interventions

SAMHSA has created new federal resources to help states, territories, tribes, and mental health and substance use disorder professionals better respond to suicide crisis events, and 988 is a large part of that effort that will undoubtedly help millions of Americans.

However, treatment and prevention still largely occur at the state or local level, and that’s where 988 currently falls short.

Today, many suicide crisis interventions involve routing people to emergency departments where they can wait for hours—or even days—for treatment. The other alternative is waiting months for an appointment with a community mental health center (where care is typically not suicide focused or evidence-based). Obviously, neither of these is optimal.

Not only are most EDs ill-equipped to assess, treat, and track suicidal thoughts, they’re also unable to keep up with the increased demand from 988. Relying on either option to treat and prevent suicide leads to wasted resources, or worse, a lack of trust in the system from clients in desperate need of urgent care.

SAMHSA has designed a 988 crisis response system — a Mobile Crisis Team — for people who are in immediate danger to themselves. And while it’s essential that these systems are implemented, most people with serious thoughts of suicide don’t want or need to be picked up and taken to a Crisis Facility.

In fact, according to National Lifeline data, less than 10% of callers are high-risk cases that require immediate intervention on this scale.

The other 90% of callers to 988 can simply benefit from a trained crisis line specialist to provide a Safety Plan and a next-day appointment to receive evidence-based treatment that specifically addresses thoughts of suicide.

And the good news is there’s a way to integrate 988 with existing institutions, like the Hope Institute, to provide better, more timely suicide interventions at locations across the country.

How The Hope Institute works

The Hope Institute integrates the best practices of a modern crisis care continuum with next-day appointments, taking referrals from emergency rooms and hospitals and relieving the strain of suicidal distress on schools, colleges, jails, sheriff’s offices, and first responders. Even better, treatment begins within 24 hours of referral.

Outpatient or telehealth—sometimes offering multiple sessions per week based on need — further increases reach across strained healthcare networks and remote rural areas with few to no services.

Hope Institutes use a combination of evidence-based, suicide-focused treatments, including the Collaborative Assessment and Management of Suicidality (CAMS) and group skills in Dialectic Behavioral Therapy (DBT).

Moreover, Hope Institutes are small, calm, and stigma free, staffed by clinicians who focus exclusively on suicide cases. And the results are clear.

Hope Institute clients are stabilized in an average of 6 weeks (adolescents in an average of 5.2 weeks). Even more impressive, a Hope Institute can be opened in just 90 days and an 18 clinician center can treat over 3,000 clients each year.

Next Steps: How to Include CAMS in your EHR

988 is changing the conversation around suicide treatment and prevention. But there’s still a long way to go to improve suicide crisis care in the US.

It’s time to integrate evidence-based best practices into your EHR, and support more responsive, effective, targeted next-day suicide interventions to communities across the country at scale.

Contact our team today to learn more about the Suicide Status Form (SSF), how you can integrate evidence-based frameworks like CAMS into your EHR, or how to bring The Hope Institute into your community.

Derek Lee – derek@thehopeinstitute.net

Andrew Evans – andrew@cams-care.com

For more information about 988, our partners at NeuroFlow wrote a helpful blog post discussing the new hotline.

For training in evidence-based, suicide-focused treatment visit CAMS Training Products.

CAMS-4Teens®

Posted on by erics

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

Research so far on using CAMS with youth

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

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

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

Promising data for evidence-based treatments for youth

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

Three funded RCTs are in progress using CAMS with youth

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

How do we best involve parents?

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

The role of the parents supporting their child’s treatment

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

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

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

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

Cultivating Perspectives | Managing Suicidal Risk, 3rd Edition

Posted on by erics

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

The 3rd and Final Edition of Managing Suicidal Risk

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

The History Behind the First Edition of Managing Suicidal Risk

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

The Evolution of CAMS

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

Perseverance and the importance of Clinical Trial Investigations

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

3rd Edition Highlights

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

Research is Hard, Expensive, & Endlessly Challenging

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

The Cultivation of Wisdom

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

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

Posted on by erics

Losing someone to suicide

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

Patients who are seriously suicidal

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

Losing patients to suicide

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

The need for evidence-based treatment

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

Using CAMS can help clinical confidence and may comfort family

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

The risk to care is worth it

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

Suicide Risk: Effective Clinical Assessment, Management, & Treatment

Posted on by erics

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

The Importance of Assessing Suicidal Risk

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

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

Suicide Screening in Managing Suicidal Risk

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

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

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

Suicide Risk Screening vs. Suicide Assessment: Understanding the Difference

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

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

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

Managing Acute Suicidal Crises: The Importance of Intervention

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

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

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

* * * * *

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

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

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

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

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

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

Lethal Means Safety and CAMS

Posted on by erics

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

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

Understanding Lethal Means Safety

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

The Nuances of Lethal Means Interventions

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

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

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

Effective Lethal Means Safety Interventions

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

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

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

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

The CAMS Evidence-Based Approach to Lethal Means Safety

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

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

Unconventional Care Saves Lives

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

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

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

The NEED for Competence and Confidence

Posted on by erics

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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