Jumping in the Hole

This guy’s walking down a street when he falls in a hole. The walls are so steep he can’t get out. A doctor passes by, and the guy shouts up, “Hey you, can you help me out?” The doctor writes a prescription, throws it down in the hole and moves on. Then a priest comes along, and the guy shouts up, “Father, I’m down in this hole, can you help me out?” The priest writes out a prayer, throws it down in the hole and moves on. Then a friend walks by. “Hey Joe, it’s me, can you help me out?” And the friend jumps in the hole. Our guy says, “Are you stupid? Now we’re both down here.” The friend says, “Yeah, but I’ve been down here before, and I know the way out.” 

“Noel” (2000) The West Wing, Season 2, Episode 10


I suffered for years with constant thoughts of ending my life, eventually coming to find comfort in them, like a blanket that would keep me warm on cold winter nights.  On the few occasions that I would share this with people, I was either dismissed outright or met with hostility, fear, or was shamed.  While it was painful and difficult for me to understand these responses, as if my verbalization of these thoughts could infect the other person, I have never been able to understand why I was met with these same responses from the mental health professionals who were supposed to be helping me.

By my sophomore year in college, I had taken definitive action to end my life three times.  Although I had been in therapy at the time of each attempt, I never told anybody.  There had already been power struggles about thoughts of ending my life, having been dismissed by one therapist and threatened with hospitalization by another; sharing about actual attempts was off the table.  At age 19, l was starting with a new therapist.  I was suicidal, self-destructive, and distrustful–my prior experiences had taught me to keep secrets.  I do not have memories of our first few sessions, but at some point early on my new therapist asked what I thought my life would be like when I was 25 and I answered honestly, saying “I don’t plan to live that long.”

Instead of being dismissive, moralizing or threatening he was empathetic, compassionate and genuinely interested in what I had to say about my own experience; I was in unfamiliar territory.  Over the next six months, I slowly learned how to trust another person and he tried everything to help me.  We started an interactive journal, each writing in a notebook and passing them back and forth at each meeting to have something between our sessions.  On a beautiful spring day following an especially difficult session, we spent an hour talking and walking around a DC neighborhood instead of sitting in the office.  I remember a particularly painful session where we both sat on the floor and I just cried, remarking that I hated crying in public and him responding with, “I don’t consider myself public.”  I did not realize it at the time, but somewhere along the way, he had jumped down into the hole with me and was desperately trying to help me find my way out.

Seven months after we started working together, on a Tuesday evening, I experienced an acute suicidal crisis.  The thoughts that had always been comforting were terrifying; I was incredibly agitated, self-destructive, and very determined.  Nothing good was going to come out of that night but instead of doing the same thing I had done on three previous occasions, I picked up the phone.  Despite our collective best effort to keep me out of the hospital, that is where I ended up–but I was alive and it was because of the strength of the relationship we had forged.  It very easily could have ended differently.

In the following weeks and months, that relationship was my sanctuary providing protection from the life I was trying to figure out if I was even interested in living.  He was unwavering in his position that my life was worth saving and steadfast in his commitment to help me but was always, always respectful when I often did not feel the same way.  Slowly, over time, my position changed.  It was not a linear path, I certainly took the long road to get there, and he stood next to me the entire way.

A year ago, I never would have even considered sharing my story but as I read the lived experience stories of others, it became clear that my experience is different in two significant ways.  First, we tried many different types of medication, alone and in combination, but nothing worked.  Despite what is often reflected in these stories, medication does not work for everybody and if it’s not working for you please know that you are not alone.  Recovery is possible without medication and while I wish it had worked, that was not to be part of my story and it may not be part of your story either.  Second, and most importantly, I had a therapist who was an expert in treating suicide.  For me, this was the game-changer.

As I shared, I saw other mental health providers prior to finding the therapist who would ultimately save my life.  While I liked all of them, they were either not trained in how to manage a patient with suicide or were working within a system that was not set-up to manage a patient with suicide.  Treating suicide is not something that most professionals are taught in training programs and many mental health systems still use threats, coercion, and practices like no-suicide contracts, which do more damage than good.

If you work within these systems, I implore you to work to change them and if you are a provider who may not be familiar with evidence-based treatments and brief-interventions for suicide, please explore the resources available to learn more and get the training necessary to implement them adherently. I am not a mental health provider, but I have been told by many that it is incredibly scary to work with people with suicide and I believe this to be true.  But standing up at the top of the hole and looking down is not what a person in the fight for their life needs or, frankly, deserves.

Perspective from a person with lived experience of serious thoughts of suicide.

CAMS Meta-Analysis: Intervention for Suicidal Ideation

I am delighted to blog about a brand-new meta-analysis of nine clinical trials showing robust support for the Collaborative Assessment and Management of Suicidality (CAMS). This landmark article has just been published in the suicide prevention field’s premier peer-reviewed scientific journal, Suicide and Life-Threatening Behavior.

The CAMS meta-analysis project was led by Dr. Joshua Swift, a well-established psychotherapy treatment researcher, and Associate Professor of clinical psychology at Idaho State University (ISU). Dr. Swift, along with two graduate students, pursued a rigorous meta-analysis of CAMS clinical trials during the summer of 2020, submitting their manuscript for peer-review in the fall. This meta-analysis was sponsored by CAMS-care, LLC with the goal of supporting an independent research laboratory to conduct a demanding and labor-intensive meta-analysis (which is a large study of various studies that meet certain specific selection criteria). It is noteworthy that Swift and his team are not suicide treatment researchers, which helped ensure a fresh and unbiased perspective to this rigorous scholarly undertaking.

To conduct this meta-analysis, the ISU research team identified over 1,000 published and unpublished articles, theses, and dissertations that referred to “CAMS” or “SSF” (the Suicide Status Form is a multipurpose assessment and treatment tool used within CAMS). Using certain selection criteria (e.g., empirical clinical trial data vs. conceptual; having a comparison control group design vs. no control comparison), the team eventually identified and selected nine9 clinical trials of CAMS comparing it to control treatments, such as “treatment as usual” (TAU) and one Danish trial comparing CAMS to Dialectical Behavior Therapy (DBT). Once the selected studies were identified, the team performed a series of statistical analyses across the studies to investigate the relative effect sizes related to clinical treatment outcomes (i.e., a measure of the relative impact of the interventions on certain key outcome variables). In other words, the overall impact of study treatments within and across all the selected clinical trials can all be compared within a meta-analysis (additional analyses related to “moderator effects” were also studied).

The results of their efforts were impressive. The research team found that, in comparison to control treatments, CAMS caused significant reductions in suicidal ideation and overall symptom distress while positively impacting hope/hopelessness and increasing treatment acceptability. There was non-significant—but trending—support for its positive impact on suicidal attempts, self-harm, and cost-effectiveness (but more data are needed to see if these effects could reach statistical significance). Importantly, in none of the nine selected clinical trials of CAMS was comparison treatment ever better than CAMS when overall “weighted averages” across studies for each clinical outcome were calculated. There were no significant differences between the use of CAMS with white vs. non-white patients (but more diverse clinical samples are needed; the European CAMS studies to date have primarily had patients who were Caucasian).

Interestingly, the clinical trials in which I (as the creator of CAMS) was directly involved did relatively worse than ones in which I was not involved! Thus, there is no “publication bias” or “allegiance effects,” which underscores the scientific objective nature of the meta-analysis evidence supporting CAMS. Dr. Swift’s team ultimately concluded that CAMS is “Well Supported” as a clinical intervention for suicidal ideation as per Center for Disease Control criteria (which is the highest level of empirical support).

Review the original article by Dr. Swift: The effectiveness of the Collaborative Assessment and Management of Suicidality (CAMS) compared to alternative treatment conditions: A meta-analysis

So, what does all this rigorous research of various clinical trials actually mean? In short, this meta-analysis of CAMS is a breakthrough investigation that caps off almost 30 years of hard-earned clinical trial research, which first focused on the early use of the SSF that later evolved into the suicide-focused clinical intervention that CAMS has become. This meta-analysis convincingly confirms that using this suicide-focused therapeutic framework works for many patients who are suicidal around the world and in different treatment settings (e.g., outpatient settings, crisis clinics, and inpatient settings). It confirms that emphasizing the four “pillars” of CAMS—collaboration, empathy, honesty, and being suicide-focused—is indeed a proven way of reliably decreasing suicidal ideation and reducing serious psychiatric distress.

One of my favorite findings from the meta-analysis is that the most robust weighted average was for the outcome of decreasing patients’ hopelessness while increasing their hope! This is an important finding about which I have previously blogged. For me, the publication of this independent and rigorous study is a career highlight and a convincing testament to the effectiveness of CAMS for patients who are suicidal around the world across a range of clinical settings. We can now say with confidence that CAMS effectively treats the most significant challenge that we face in the field of suicide prevention today: the massive population of people who struggle with serious thoughts of suicide. Given the evidence, we believe that CAMS can effectively treat the “iceberg” of people with suicidal thoughts, a population 225 times greater than the population of those who take their life (Reflections on Suicidal Ideation). If we succeed in our efforts to train more clinicians to provide “upstream” effective CAMS-guided care to those who struggle with serious suicidal thoughts, perhaps we can help divert such patients from going on to attempt suicide or even prevent them from suicide further “downstream.” Thus, the publication of this new meta-analysis supporting the use of CAMS by Swift and colleagues is a major breakthrough to realizing the ambitious goal of reducing suicide-related suffering in all its forms around the world.

* * * * *

Background on the CAMS Framework

CAMS is a therapeutic framework for effectively treating suicidal risk. It evolved from a line of suicide risk assessment research that initially began at the University Counseling Center at The Catholic University of America in the late 1980s. The key tool in CAMS is the Suicide Status Form (SSF) which guides all clinical activity within the intervention—from the initial session, across all interim care, to the outcome/disposition session, which concludes the use of CAMS. The SSF, therefore, functions as a multipurpose assessment, treatment planning, tracking, to clinical outcome tool. Previous research has shown that the SSF serves as a “therapeutic assessment.” CAMS SSF-based treatment planning focuses on patient-identified suicidal “drivers,” which are the problems that compel them to consider suicide (e.g., a relational breakup or self-hate). CAMS, therefore, targets and treats the patient’s suicidal drivers over the course of care to achieve optimal clinical outcomes such as rapid reduction of suicidal thoughts (in as few as 6-8 sessions), decreased symptom distress, and decreased hopelessness with increased hope.

CAMS’s Purpose and Function

The purpose of CAMS is to engage a person who is suicidal in a strong therapeutic clinical alliance while increasing their motivation to be an active collaborator within their tailored suicide-focused care. CAMS thus functions as a guiding framework to help stabilize the patient’s life while suicidal drivers are addressed and treated throughout the course of care. CAMS concludes with a focus on purpose and meaning and the pursuit of a life worth living.

How Clinicians Utilize CAMS

Clinicians across a range of clinical settings use CAMS to effectively stabilize and treat patients who are suicidal. The framework is atheoretical, which means that it is not tied to a particular theoretical orientation or set of techniques. The SSF provides structure for assessing suicidal risk at the start of each session and ensures that the suicide-focused treatment plan is updated at the end of every CAMS-guided session. The SSF also helps create extensive medical record documentation that reflects effective suicide-focused assessment, treatment planning, and follow-through. This kind of documentation reflects good practice and helps decreased the risk of malpractice liability related to working with patients who are suicidal.

Why CAMS is Effective in Reducing Suicidal Ideation and Associated Issues

Research has clearly shown that when CAMS is used adherently, it reliably reduces suicidal ideation and overall symptom distress, while increasing hope, and improving retention to clinical care. While more research is needed to understand the exact mechanisms of CAMS, we believe that a strong clinical alliance along with empathy and validation are essential ingredients to all successful CAMS-guided care. Research also shows that CAMS seems to change the patient’s “relationship” to suicide, providing alternative coping methods and getting needs met. Beyond helping patients become less suicidal, CAMS also encourages patients towards the end of care to actively consider the pursuit of plans, goals, and hope for the future within a life worth living—a “post-suicidal” life—a life with purpose and meaning.

The Need for Effective Suicide Interventions

There are remarkably few proven-effective clinical treatments for patients who are suicidal. Many practitioners rely on inpatient hospitalizations and psychotropic medications which have limited to no evidence for being effective with suicidal risk. Other effective treatments like Dialectical Behavior Therapy (DBT) or suicide-specific Cognitive-Behavioral Therapy (CBT) are more effective with decreasing suicide attempts, whereas CAMS reliably treats the much larger population of people with serious suicidal thoughts. Moreover, CAMS is relatively easy to learn compared to DBT and CBT and is generally more flexible and adaptable to different settings and theoretical orientations compared to other effective suicide treatments.

The Merit of CAMS is Undeniable

CAMS is a proven and effective treatment that is relatively easy to learn and ensures good practice and documentation that helps decrease practitioner exposure to liability. Research has shown that patients significantly prefer CAMS to usual care, and training in CAMS has been shown to increase provider competence and confidence, which are critical to successful care.

Case Example

In a randomized controlled trial of CAMS conducted at a U.S. Army infantry post, there was a multiply deployed Soldier “John” who came into treatment after being referred by his commander. John had significant combat-related trauma, and he was extremely upset that his ex-wife was moving to another state taking their two young sons. His CAMS clinician—a skilled clinical social worker—engaged him with the SSF in the first CAMS session. They readily identified his suicidal drivers: combat-related PTSD and the potential loss of access to his sons.

Over the course of ongoing interim CAMS care, the clinician effectively treated the Soldier’s PTSD with cognitive processing therapy (CPT). The clinician also arranged for the Soldier to meet with a JAG officer to receive legal consultation related to gaining joint child custody. Beyond treating his drivers, a significant issue with this Soldier was the clear need for John to leave the Army because of his inability to engage in further combat deployments (given the PTSD from his four previous combat deployments). During interim CAMS sessions, the clinician was able to gently persuade John to consider a medical separation from the Army, and together they engaged a VA provider who could see John after separation. They also explored various job options he could pursue as a civilian. Within a few weeks, with legal help from JAG, John obtained joint custody of his children and secured an arrangement for parental visitations. By session 9 of CAMS, John no longer had suicidal thoughts. While he was sad to leave the Army, John was excited about some job opportunities and the prospect of getting an associate degree with his VA benefits. John’s suicidal ideation had significantly resolved in fairly short order, and his symptoms of PTSD and anxiety were notably reduced. John actually felt hopeful about his future and ultimately became eager to leave the Army for a promising life outside the military.

In John’s case, we see all the elements of what Swift et al. found within their landmark meta-analysis of nine CAMS clinical trials. At the conclusion of CAMS, John began to realize a post-suicidal life—one with promise and potential for having successfully completed a therapeutic course of CAMS-guided care. While there were no doubt challenges ahead, John found his way out of a suicide crisis that put his life in peril. After his treatment, John saw that there could be life beyond being a Soldier,; a life with purpose and meaning—a life worth living.