Where You Work: Crisis Stabilization

Suicide Risk Factors and Warning Signs: What we’ve learned from the research

It’s important to understand that there are many potential suicide risk variables, the following are a subset of variables with strong empirical research support.

SUICIDE RISK FACTORS

Suicide risk factors are diverse and multifaceted, encompassing a range of individual, social, and environmental factors. They include personal characteristics such as mental health conditions, previous suicide attempts, substance abuse, and other factors. Understanding and addressing these factors can aid in suicide prevention efforts.

History of Suicidal Behaviors

The history of previous suicide attempts has long been considered a major risk factor related to future suicidal behavior. The risk of such future behavior increases significantly with any past attempt behaviors, particularly a multiple-attempt history of two or more bona fide attempts. 

Suicidal Thoughts & Ideation

When a person has suicidal thoughts, the details and frequency of these thoughts are critical. It’s important to determine whether such thoughts are a brief passing fantasy or something they have explored, made a plan and taken specific actions. By directly asking a person whether they are thinking about taking their life, with appropriate follow-up questions, you will be better able to assess their risk of suicide. Contrary to some popular beliefs, several research studies have clearly shown that asking a person suicide-related questions WILL NOT put the idea of suicide in their head.

Do not be afraid to ask, something like:  “It sounds like you are having a difficult time, have you ever wished you were dead?” or “ It sounds like you are really struggling, have you ever wished you could just go to sleep and not wake up?”.  

  • If the answer is “no”, ask: “In the past three months, have you thought about taking your life, or prepared to do anything that could end your life?”
  • If the answer is “yes” ask: “Have you thought about how you might do this?”

Asking your friend or family member to describe their suicide-related thoughts and provide specifics on the frequency and duration of these thoughts will not only help you better understand your loved-one’s struggles and suicide risk factors, but also send them a clear message that you truly hear them and want to listen. You are telling them that they are not alone and you are willing to try and understand their pain.  

Suicide Plan

While suicidal thoughts are an important suicide risk factor, research has indicated that the specific details and seriousness of planning and preparing for suicide can be predictive of the likelihood of future death by suicide. In other words, someone with a vague, inexact, or nonspecific plan is generally much less serious about taking their life, as opposed to someone with a plan that includes a particular method, place, time, and date for how they will end their life.   

The next important question to ask a friend or family member who has shared their suicide plan with you is whether they have access to the item or method they plan to use for carrying out the plan, such as a stash of sleeping pills or access to a firearm. These items are referred to as “lethal means”, and limiting their access can be an important step in suicide prevention. You might ask: “Have you started to work out the details of how you plan to kill yourself?” or “Do you have an idea of where and when you will do it?”

If your friend or family member does have access to the lethal means that they describe in their suicide plan, your next critical step is to work with them to develop a “safety strategy” to remove their direct access to the lethal item, at least until their suicidal crisis is over. For example, are they willing to let you hold their pills for safe keeping?  Are they willing to let an appropriate and trusted friend or relative keep their gun until their suicide crisis is over? Are they willing to take a different route to work or school so that they do not walk by railroad tracks?  Are they willing to avoid parking their car in a tall parking structure?  

Suicide Preparation

In general, preparation behaviors are often related to organizing the suicide attempt action itself, such as obtaining the lethal means, as well as doing research to determine a lethal dose of drugs or determining a suitable location where the possibility of interruption or intervention may be reduced. Other preparation behaviors may include putting one’s affairs in order, such as writing a will, writing suicide notes, shooting a good-bye video, posting a cryptic Facebook message, doing a favorite activity one final time, saying a final good-bye to friends and family, or giving away prized possessions. All of these behaviors may indicate significantly increased suicidal risk for the individual. In these circumstances, you might ask: “Have you collected pills?” or “Have you obtained a gun?” or “Have you given away valuables, written a will or a suicide note?

Suicide Rehearsal

“Rehearsal behaviors” is a suicide risk factor that typically involves the acting out of the planned suicide attempt. For example, someone may obtain a rope, find a beam in the garage, secure the rope at a certain length, position a short stool, and even step up on the stool and place the rope around their neck without actually stepping off the stool to make the attempt. Such rehearsal behavior is serious.  You might ask: “Have you held the gun, but changed your mind?” or “Have you cut yourself?” or “Have you hung a rope?”

WARNING SIGNS of Suicidal Ideation

In contrast to risk factors “warning signs” for suicide typically center on being extremely upset and agitated —when someone feels totally out of control. Warning signs for suicide suggest an immediate risk of self-destructive behavior. For example, in the case of heart disease (which is the #1 cause of death around the world), many people have both short and long term risk factors (e.g., obesity, hypertension, high cholesterol, and smoking) but do not die of heart disease. In contrast, someone with such risk factors might have key warning signs that prompt urgent intervention to avert a heart attack (e.g., chest pains, pain in their left arm, feeling faint). 

Below are various topics when experienced in a very serious manner can contribute to imminent for self-harm behaviors, such as cutting or burning one’s skin, over-dosing and suicide attempts.

Severe Substance Abuse

The extremely excessive use of alcohol or drugs during a crisis can directly contribute to being highly upset and out of control which may trigger individuals to harm themselves or even make a suicide attempt.

Impulsivity in Decision Making

Generally, impulsivity refers to the lack of ability to think through the consequences of one’s actions, in other words “acting without thinking”. Suicide attempts and deaths often occur when someone is upset, distressed, anxious, highly emotional and/or highly impulsive. The risk is further increased if impulsive behaviors are essentially self-destructive, for example, a history of fighting, pathological gambling, kleptomania, or other similar impulsive disorders.  

Extreme Reaction to a Death or Significant Loss

For many years, suicidologists have known that suicides often occur after someone has experienced a loss, which may seem to trigger the suicidal act. Such losses may be big or small; it can be one particularly significant loss or an accumulation of several lesser losses. Examples may include a divorce, a romantic breakup, a financial disaster, loss of a job, the death of a loved one or a pet— any event that has significant meaning to the person. Additionally, suicide-triggering losses can be symbolic—for example, retirement from a meaningful career. Although losses often contribute to the circumstances leading up to a suicide, usually such losses are not the only reason for suicidal behavior. 

Critical Relationship Problems

Research studies have shown that relationship issues are often the number one suicide-related concern of people struggling with suicidal thoughts. These problems could be romantic issues or relationships with friends, parents or siblings. In contrast, we also know that social relationships can protect a person against suicide. It is important to not let the highly suicidal person be or feel alone. The perception of being a burden to others can be a particularly important relationship problem when experienced by someone who is extremely upset. Experiencing oneself as a burden on others can create a dangerous downward spiral, wherein the individual experiencing suicidal ideation is disinclined to seek help. In the mind of the person with suicidal thoughts, their suicide can be perceived as a “gift” to the people in their lives who they believe are “weighed down” with the troubles of the person who struggles with suicide. 

Chronic Pain and Severe Health/Pain Problems

There are studies that suggest that general health-related issues, particularly if these issues are constantly occurring or chronic, may be related to suicidal thoughts and behaviors – particularly if these issues are chronically occurring or terminal in nature. While many people live out their lives in chronic physical pain, other can find such pain to be utterly unbearable, which may lead to increased suicidal thoughts as a way to finally escape the pain. 

Serious Sleep Problems & Insomnia

Sleep problems related to insomnia, hypersomnia, and nightmares have been shown to be significant suicide risk factors in adolescents and adults and the lack of sleep impacts REM sleep which is critical to everyone to maintain, and the heightened stress levels caused by lack of proper sleep can exacerbate a sense of peace and calm.   

Legal/Financial Crisis

Legal problems can contribute significantly to suicidal risk.  There is often a window of considerable suicidal risk shortly after a person is first faced with a legal accusation. Similarly, financial issues from poverty, unemployment, credit card debt, payday lenders, owing back taxes, and simply not being able to make ends meet can all contribute to increased suicidal risk. 

Suicide is Different Website

Suicide is Different: A web-based resource that provides support to those supporting someone who is thinking about suicide. Here you can learn more about suicide through activities and videos, plan ahead for your own wellness as a suicide caregiver and connect with group support and workshops.

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.

Trillium Case Study: Suicide Prevention – A consistent approach with tailored treatment

A Consistent Approach to Suicide Prevention

Dr. Ian Dawe is a Psychiatrist in Ontario, Canada and an expert in suicide prevention. As a Fellow with the University of Toronto’s Arthur Sommer Rotenberg Chair, Dr. Dawe worked with many partners to advocate for the Luminous Veil, the barrier that now successfully prevents suicides at the Bloor Street Viaduct: “Getting people to pause and reconsider their decision frequently results in changed minds.”

As Chair of the Ontario Hospital’s Task Force on Suicide Prevention Standards, Dr. Dawe leads a group of provincial experts, including many with living expertise, to bring effective suicide prevention standards to all of Ontario’s hospitals.

Dr. Ian Dawe

Dr. Dawe envisions a zero suicide plan for Ontario. “The suicide rate hasn’t changed in 15 years—that’s because we haven’t decided to change it together. Like any quality improvement project, you first need a target.”

In 2014, Dr. Dawe was part of a Provincial Taskforce that explored improving care for people with serious thoughts of suicide across 150 hospitals in Ontario. The team knew that a systems-level approach would provide residents with consistent clinical delivery and ensure high-fidelity, evidence-based care replicable at scale.

They selected the Zero Suicide Framework.

The Fifth Element – Treat

In 2016, Dr. Dawe took a position at Trillium Health Partners in the suburbs of Toronto as Program Chief of Mental Health. Trillium serves the most populous and ethnically diverse catchment area across three hospital systems: 2,000,000 people and 130 mental health hospital beds. Dr. Dawe continued to pursue the Zero Suicide Initiative. He also had the opportunity to attend a conference in Sydney Australia in 2017 where Dr. David Jobes gave a presentation on the Collaborative Assessment and Management of Suicidality (“CAMS”).

Trillium had previously invested in DBT, which was used to treat addiction, depression and other acute cases. CAMS was different. It was suicide specific.

Dr. Dawe saw the benefits of the documentation and structure of the CAMS approach so that “patients with serious thoughts of suicide wouldn’t get [his] version of treatment; they would get a consistent version of CAMS.”

Partnering for Greater Patient Care

Active patient involvement is essential to patient-centered care for Dr. Dawe: “Patients and families are the experts—they have living expertise. We have training and compassion. When we collaborate with patients and each other, we create real change.”

He is a strong believer in meaningful partnerships that benefit patients, including aligned mental health care. “We are all of us—physicians and patients—so much better when we work together,” he says. “In both my patient care and administrative duties, I have endeavored to empower patients and their families to be actively part of the process, to make better decisions—this enhances their care.”

CAMS gave Dr. Dawe a blueprint to take to his team. CAMS shares the philosophy in which the patient is the expert in his/her own suicidality. The clinician has the knowledge, and together the patient and the clinician collaborate to create a treatment plan.

Elevating the Standard of Care

The Emergency Department “is still the biggest entry point for care, and yet hospitalizing patients and watching them didn’t do anything. It probably made it worse,” said Dr. Dawes. “The old way didn’t work!”

Trillium established a CAMS Clinic in September 2020 which is open 9 AM to 8 PM, six days a week. During the pandemic, people have not been seeking help in person as much, so the clinic switched to using telehealth for all 69 cases since it opened. Not everyone presents as suicidal during regular clinic hours, so it is imperative that each person receives the same standard of care regardless of time of day.

Dr. Dawe and his team believe that doing suicide care well is a treatment unto itself.

Step 1 – Admission to the ED and the Columbia Short Screener

The goal is for a suicidal person to be seen as quickly as possible, although people seeking mental health care often find themselves subordinate to the demands on the medical staff to treat physical health crises. When the patient is seen by a doctor or nurse, the medical staff are trained to use the Columbia Short Screener with its six questions. It takes roughly four minutes to administer. There was no singular reason for selecting the Columbia; the goal was to choose a single approach and implement it well.

Step 2 – The Crisis Team

When someone screens as suicidal, the crisis team gets involved, and a psychiatrist consults with the patient. Depending on the evaluation, patients may visit an urgent follow-up clinic or, in less acute cases, the CAMS Clinic. Many patients are hospitalized overnight because it provides a safe place, allowing the crisis team and the patient to re-evaluate the plan the following day.

Step 3 – The CAMS Clinic

The CAMS Clinic reaches out to the patient to set up an appointment 48 to 72 hours after the overnight stay. Then the treatment journey begins. At every step along the treatment journey, the patient receives the Columbia Short Screener. The rating scale on the CAMS Suicide Status Form, while not perfect, provides a judgement of patient progress that is more concrete than a gut feeling and points to how the patient improves over time.

Step 4 – Social Services

As a patient’s distress decreases and their hope increases, social services assist with job and food insecurity, housing, legal help and more to build a life worth living.

The Trillium approach is applied consistently while allowing for treatment tailored to the individual. The process is rapid and handoffs between providers are closely monitored.

Training in CAMS

The training and support in CAMS have been excellent. Dr. Ray Tucker, who led the roleplay training and consultation calls, is part of a system of care at Our Lady of the Lake in Louisiana that uses CAMS across psychiatric inpatient units, geriatric inpatient units, psychiatric consult services, and outpatient care at its Regional Medical Center in Baton Rouge.

Grand Rounds with Dr. Jobes was another highlight in Trillium’s training and implementation process.

Ontario-Wide Adoption

Other hospitals in the region are aware of the traction at Trillium, which is the region’s Implementation Science center. Dr. Dawe believes it is only a matter of time before a growing number of Ontario hospitals implement CAMS at scale.

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

Interventions 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 individuals better than any other clinical treatment available, with promising data on suicide attempts and self-harm as well. CAMS is not a one-size-fits-all solution, but it is an excellent option for the largest population in the field of suicide prevention: the 12 to 14 million Americans of all ages who experience serious thoughts of suicide.

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

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

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

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

Dr. Rory O'Connor

About Dr. Rory O’Connor

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

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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” were 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.

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

Posted on by erics

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

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

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

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

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

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

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

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

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

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

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

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

NAViGO’s Implementation of CAMS System of Care in UK: Preliminary Positive Outcomes

In 2017, NAViGO Community Interest Company implemented CAMS as part of their National Health Service-commissioned health and social care services in the United Kingdom, for a highly deprived ward with a population of over 165,000 people.

Within two years of implementing this system of care for Mental Health, the following preliminary outcomes have been realized:

• Increased healthcare clinicians’ confidence in assessing and treating suicidal patients
• Greatly reduced waiting time for care
• Reduced number of individuals requiring a Crisis contact
• Lower average of Crisis total contacts and fewer individuals requiring subsequent inpatient admissions
• Reduced local suicide rates (preliminary data suggest a reduction of 80%)

While data is preliminary at this early stage of the implementation, the short-term trends observed are expected to be replicated over the full term of the project.

The article, available for download below, published with permission, describes the processes and outcomes of NAViGO’s custom implementation of CAMS as their primary system of care for suicidality among the mentally ill in this community. It is the hope of all of us at CAMS-care that more communities around the world can replicate a similar system of care for similar positive outcomes in reducing the number of suicides in their own health care systems.

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Journal Of Affective Disorders

A group in Oslo, Norway recently studied managing suicidality within specialized care, including patients from two crisis centers, three inpatient units, and two regular inpatient units. The study found that “CAMS improved treatment outcome on suicide ideation and mental health distress more rapidly and in a sustained manner when compared to treatment as usual.” This study is in press at the Journal of Affective Disorders.

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Journal Affective Disorder CAMS Improved Treatment