Where You Work: Inpatient Settings

New Directions in Suicide Safety Planning: The Project Life Force (PLF) Intervention

Dr. Goodman describes the development and testing of a novel treatment – “Project Life Force (PLF)” – which combines aspects of two evidence based treatments: Suicide Safety Planning and Dialectical Behavior Therapy Skills. The intervention is delivered in a group format and virtually since the pandemic. PLF framework, clinical data and implementation efforts were reviewed.

Marianne Goodman, PhD

Marianne Goodman, MD

Dr. Goodman has been a full time VA clinician (psychiatrist)-scientist at the James J. Peters VA Medical Center (JJPVA) for twenty-five years. In addition to being the Director of the VISN 2 Mental Illness, Research, Education, Clinical Center (MIRECC), she was the Director and developer of the JJPVA Dialectical Behavioral Therapy (DBT) Clinical and Research program from 2002-2015 and Director of the JJPVA Suicide Prevention Clinical Research Program from 2015-present. Her expertise is in the management of high risk suicidal and emotionally dysregulated Veterans and is considered one of the top suicide prevention experts in the VA system, actively involved in clinical care, research and education. Additionally, she has been the recipient of several prestigious awards for her involvement in suicide prevention and DBT treatment including the New York Federal Executive Employee Outstanding Individual Achievement Award for her Clinical DBT Program for Suicidal Veterans (2009), VISN 3 Network Director’s Achievement Award for Training VISN 3 Clinicians in DBT (2012), and the New York State Excellence in Suicide Prevention Award for Implementation of Zero Suicide in a Healthcare Setting (2018).
In 2015, she shifted her research direction to focus on treatment development for suicide prevention and designed “Project Life Force” (PLF) a novel group intervention that adapts DBT, combining emotion regulation skills with suicide safety planning and lethal means safety which was initially funded with a VA RR&D SPiRE pilot grant (2016-2018), and more recently funded with a multi-site VA RCT with a CSRD Merit (2018-2024). This intervention has moved to full telehealth delivery and with a 2021 SPRINT pilot award expanded to target populations of suicidal rural Veterans (PLF-RV). Dr. Goodman will present on her Project Life Force Intervention.

David A. Jobes, PhD

About David A. Jobes Ph.D. ABPP

David Jobes, PhD, ABPP, is the founder of CAMS-care, LLC. He began his career in 1987 in the Counseling Center of the Catholic University of America, where he developed a suicide risk assessment tool for college students that evolved into CAMS. Dr. Jobes is now a Professor of Psychology and Associate Director of Clinical Training at Catholic; he has trained thousands of mental health professionals in the United States and abroad in evidence-based assessment and treatment of suicide risk and the use of CAMS.

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2024 CAMS Update and Introducing CAMS Brief Intervention

2024 CAMS Update and Introducing CAMS Brief Intervention

In this suicide prevention month webinar, Dr. Jobes will discuss recent updates based on clinical trial research, clinical use of CAMS, and training developments related to CAMS. With five on-going randomized controlled trials and a series of recent publications, there is much news to report on all things CAMS. Dr. Jobes will then be joined by Dr. Ray Tucker who will present on the emerging use of CAMS as a single-session brief inpatient and/or emergency department intervention with promising preliminary evidence. There are now several new research efforts to replicate and extend early CAMS-BI™ findings. Join us for this exciting update and introduction to CAMS BI as a novel and much needed suicide-focused brief intervention.

David A. Jobes, PhD

About David A. Jobes Ph.D. ABPP

David Jobes, PhD, ABPP, is the founder of CAMS-care, LLC. He began his career in 1987 in the Counseling Center of the Catholic University of America, where he developed a suicide risk assessment tool for college students that evolved into CAMS. Dr. Jobes is now a Professor of Psychology and Associate Director of Clinical Training at Catholic; he has trained thousands of mental health professionals in the United States and abroad in evidence-based assessment and treatment of suicide risk and the use of CAMS.

Dr Raymond Tucker Headshot

About Dr. Raymond P. Tucker

Associate Professor of Psychology, Louisiana State University (LSU)
Clinical Assistant Professor of Psychiatry, Louisiana State University Health Sciences Center (LSUHSC)/Our Lady of the Lake (OLOL),
Raymond P. Tucker is a licensed clinical psychologist and associate professor of psychology at Louisiana State University. There he teaches undergraduate courses in psychology, graduate courses in clinical psychology, and founded the LSU Mitigation of Suicidal Behavior research laboratory. As a clinical assistant professor of psychology at LSUHSC/OLOL, he trains medical staff/students in suicide-specific evidence-based assessment and intervention protocols.

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Jumping in the Hole

Posted on by erics

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.

Zero Suicide – Outcomes and Opportunities

Zero Suicide - Outcomes and Opportunities

The Zero Suicide model was launched in 2012 as part of the National Action Alliance for Suicide Prevention. Consistent with the National Strategy for Suicide Prevention, Zero Suicide called for improved suicide identification and care in health care systems and promoted use of evidence-based practices by health care providers. Seven core elements comprise the model: “Lead”, “Train”, and “Improve” are the structural components embedded throughout the system and necessary for change, success, fidelity, and continuous quality improvement. “Identify”, “Engage”, “Treat”, and “Transition” are clinical components of the model and define the care patients should receive. Despite evidence supporting each component, use of the full model within systems of care varies.

Over 38% of individuals have made a healthcare visit (e.g., primary care, emergency department, specialty care, etc.) within the week before their suicide attempt and 95% have had a healthcare visit within the preceding year. While this varies across race and ethnicity, these are clearly missed opportunities to identify and care for people at risk for suicide.

Seeing suicide as a never event forces the organization to use best practices, apply continuous quality improvement, and emphasize reducing errors while holding the system to account, not the individual. The clinical science of treating suicidality has evolved such that we now have several proven suicide-specific treatments with additional promising treatments in development. However, graduate programs, professional certification, and continuing education rarely focus on suicide-specific treatments as a competency for graduation or licensure and clinicians report a lack of comfort, confidence, and skill in delivering suicide care.

The Zero Suicide approach has demonstrated notable reductions in suicide and suicide behaviors as well as improvements to using evidenced-based practices. This webinar will describe the Zero Suicide model, discuss challenges, disparities, and opportunities regarding uptake of the unique components of the model, and share how organizations can get started on their Zero Suicide implementation efforts.

Julie Goldstein Grumet, PhD

Julie Goldstein Grumet, PhD

Julie is Vice President for Suicide Prevention Strategy and the Director of the Zero Suicide Institute at the Education Development Center. She provides strategic direction to health care systems to improve the identification and treatment for people at risk for suicide. She has collaborated on numerous grants and publications about systems-based approaches to suicide prevention. Julie’s primary responsibility is to advance the development, dissemination, and effective implementation of comprehensive suicide care practices in various settings. She has expertise in behavioral health transformation, state and local community suicide prevention, quality improvement, and the use of evidence-based practices for suicide care in clinical settings. Julie has a Ph.D. in Clinical Psychology from The George Washington University and lives in Silver Spring, MD.

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Innovations in Clinical Suicide Prevention: 2023 CAMS Update and the 3rd Edition of “Managing Suicidal Risk”

Innovations in Clinical Suicide Prevention: CAMS Update and the 3rd Edition of "Managing Suicidal Risk” On-Demand Webinar

This webinar provides a major update on the use of CAMS focused on the third and final edition of “Managing Suicidal Risk: A Collaborative Approach” published by Guilford Press. This webinar delves into the latest research and tools presented in the new book, written for mental health clinicians dedicated to treating their patients experiencing serious thoughts of suicide.
Explore the key highlights of the new book, including the:

  • Updated Suicide Status Form (SSF-5) for comprehensive risk assessment and suicide-focused treatment
  • CAMS-4Teens®: Engaging parents and families in adolescent care using the new Stabilization Support Plan (SSP)
  • Exploration of post-suicidal life and the optional Living Status Form (LSF)
  • Further insights on CAMS driver-oriented treatment planning
  • Major revision of the CAMS Therapeutic Worksheet
  • Suicide Status Form is available digitally for telehealth and electronic health records

Don’t miss this opportunity to hear directly from Dr. Jobes during Suicide Prevention Awareness Month. Hosted by Dr. Kevin Crowley, clinical psychologist, private practitioner and CAMS Consultant.

 

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Big Ideas for Advancing Suicide Prevention

Posted on by erics

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

My Final Decade of Suicide Research

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

A Lack of Progress in Reducing Suicidal Suffering

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

Focusing on Suicidal Ideation

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

Jaspr Health – Providing Hope during ED Visits

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

The Hope Institute – Keeping Suicidal Patients out of the Hospital

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

Mental Health Service Corp

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

* * * * *

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

Empirical, Clinical, and Conceptual Evidence Converges to Indicate Good Support for the Interpersonal Theory of Suicide

Empirical, Clinical, and Conceptual Evidence Converges to Indicate Good Support for the Interpersonal Theory of Suicide On-Demand Webinar

In this webinar, Thomas Joiner, Ph.D. discusses the topic of Empirical, Clinical, and Conceptual Evidence Converges to Indicate Good Support for the Interpersonal Theory of Suicide.

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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 understanding subtext in communication (takes things literally)

Autism is not a mental health disorder nor a disease; although mental disorders and physical disabilities do co-occur.[5] In 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 often 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 SSF 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 autistics, 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 Clinical Management of Suicide Risk

10 Tips for Clinical Management of Suicide Risk On-Demand Webinar

In this hour-long webinar, “10 Tips for Clinical Management of Suicide Risk,” clinicians often face anxiety and uncertainty in managing and treating suicide risk. This presentation will highlight ten helpful and scientifically informed tips that clinicians can begin to use immediately in the context of their practice.

Marjan G. Holloway, Ph.D.

About Marjan G. Holloway, Ph.D.

Dr. Holloway is a Professor of Medical and Clinical Psychology and Psychiatry at Uniformed Services University (USU), a Diplomate of the Academy of Cognitive Therapy, and an Adjunct Faculty Speaker and Consultant at the Beck Institute for Cognitive Behavior Therapy and the Zero Suicide Institute. She completed her postdoctoral training in 2005 at the Center for the Treatment and Prevention of Suicide at the University of Pennsylvania under the mentorship of Dr. Aaron T. Beck. As the Founder and Director for the USU Suicide Care, Prevention and Research Initiative, Dr. Holloway and her team have developed and disseminated a number of evidence-informed psychosocial programs to address the public health burden of suicide as highlighted by (1) the Air Force Guide for Suicide Risk Assessment, Management, and Treatment; (2) the Chaplains-CARE program; (3) Special Operations Cognitive Agility Training (SOCAT); (4) Rational-Thinking and Emotional-Regulation through Problem-Solving (REPS) for newly enlisted military personnel; (5) Mil-iTransition for Service members receiving unfit for duty determinations; and (6) Post-Admission Cognitive Therapy (PACT and PACT-Together) for psychiatric inpatient settings and Intensive Outpatient Programs. Dr. Holloway maintained a part-time private clinical practice for 15 years, shifting recently to a consulting practice.

Watch the Recorded Webinar On-Demand

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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.