Where You Work: Inpatient Settings

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

Posted on by erics

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

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

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

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

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

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

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

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

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

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

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

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

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

Posted on by erics

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

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

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

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

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

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

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

Cams-care Image

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

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

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

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

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

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

A Guide to Contextualizing the Reality of Systemic Racism and Black Suicidology – Part 3: Working with Suicidal Black Youth

On our journey of enlightenment and understanding the mechanisms of Black suicidality, we have explored the socio-historical context, current literature, and treatments available towards mental health care. By utilizing an intersectional lens, we began to unravel the complexities of systemic racism and how those processes influence and trigger suicidal behavior among Black Americans. It illustrates the erasure of methodology and treatment centered towards the Black experience within the U.S. Like a worn-out washing machine, it continues to perpetrate the cycle of institutionalized violence.

Now what? It is important to articulate the discourse around Black suicidology, but discourse by itself is an empty vessel. Even more relevant is the ability to apply knowledge to practice. In this final part of this series, we will conceptualize the implementation of effective treatment on suicidal Black youth, which has been alarmingly on the rise these past few years. Although we have been taken a macro analysis of Black suicide, I think it is important to center our lens towards the current crises: Black adolescents.1

Internal & External Risk Factors

As we have discussed in the previous parts of this series, there is a magnitude of risk factors that influence Black youth suicidality. I have compiled a list of internal and external risk factors that possibly influence suicidal behavior among Black adolescents:

  • A history of mental health disorders.
    Research suggests that Black children with a history of mental health disorders (i.e., depression, anxiety, ADHD, etc.) are at higher risk to die by suicide.2 Factoring the prevalence of misdiagnosis and underdiagnosis of Black mental disorders, these suggestions are alarming.
  • Bullying victimization.
    Black children raised in predominately White neighborhoods experience increased peer bullying, institutionalized racism, lower academic performance, and higher suspensions than their White counterparts.3 Trends show these children (ranging from school age to adolescence) use more lethal means such as suicide by hanging.
  • Lack of family/community cohesion.
    Within marginalized groups, family and community are important components of social survival. Family/community cohesion is the perception and inclusion of an individual within their identity groups, enabling a feeling of inclusion and the action of support. Sometimes these cohesive structures maybe broken due to social, economic, and other structural stressors. An individual that does not have family/community cohesion may exhibit feelings of isolation, burdensomeness, and hopelessness.
  • Inaccessibility to mental health services.
    Mental health services are often inaccessible to individuals who reside in low-income communities. Without the means to affordable and accessible care, suicidal behavior is not addressed or left unchecked.
  • Mental health stigma.
    The average person is not fully versed on the scientific and psychological understandings of mental health. There are numerous taboos and perceptions about suicide that may hinder treatment. Some religious, cultural, and social backgrounds may perceive suicidal behavior as a manifestation of “weakness” or “crazy-behavior”. These views help to stigmatize suicidal individuals.
  • Racial biases among mental health providers.
    As we have previously discussed, there has been a racialized bias, and even intentional mistreatment, of Black patients within the mental health field. This can be presented as the perception that Black people are so mentally and physically “strong” that suicide might not be a problem, or they have a higher threshold for the stressors that lead to suicidal behavior. This may lead to dismissal of an individual’s mental health needs.

Treating Black Youth Suicidality

While working with Black clients, I have established three main goals that I think are essential to the therapeutic process. These objectives can be implemented across your therapeutic style, whether CBT, psychoanalyses, or a mix-treatment. The aim is to build a foundation of trust between the client and the provider. The initial process of therapy should include the following steps:

  1. Identify Risk Factors.
    Address the core issues presented by your client. Suicidal behavior among Black youth is not isolated. In my opinion, it is a residual effect of environmental, social, genetic, and psychological stressors. It is like a puzzle piece, a small component of a larger picture. It is influenced by many other factors, and to effectively address suicidal behavior you must identify and acknowledge the risk factors that influence the client’s suicidality.
  2. Affirm Their Experiences.
    Affirming the client’s experiences is crucial because it provides it provides a safe space in the context of solidarity and helps to re-distribute the power dynamics in the relationship. Affirmation of the individual allows them to feel and experience a sense of control, while allowing the therapist to embrace empathy.
  3. Speak Truth to Power.
    There is power in words. In expression. Vocalization is the act of giving voice what is voiceless. It is providing the tools necessary for an individual’s enlightenment of self and the support system. This can be presented in the form of education through family/community engagement, client narrative writing (journaling), or a tool such as the CAMS the suicidal status form (SSF), which allows the therapist and client to note suicidal behavior through a collaborative exercise.

I try to implement these objectives in both my academic and clinical work. They can be generalized to every patient; however, I find that keeping these three objectives in mind helps me to provide a more holistic approach when working with Black adolescents.

Case Studies: Practicing the Identify-Affirm-Speak Method

Tiffany

Tiffany is six years old. She lives in the suburbs of Northern Virginia with her parents. She attends a predominately White primary school and is the only Black student in her classroom. Tiffany is often bullied by her peers due to her physical appearance. She is beginning to feel isolated from her classmates. Tiffany informs her teacher about the bullying. The teacher assures her that if she ignores the bullies, the bullying will stop.

The bullying does not stop. It continues and begins to affect her academic performance. Tiffany, a recently high achiever, has not been completing her assignments and is not engaged in class discussions. Her teacher remarks to her parents that Tiffany’s behavior has become detached and rude towards others. Tiffany’s mother has also noticed negative changes in her behavior. She labels Tiffany’s behavior as lazy and disrespectful.

Tiffany attempts to avoid school by stating she feels sick during the weekdays, and on the weekends, she sleeps the whole day. Tiffany also spends a lot of time on the computer. Her mother has discovered her recent search history includes “how to kill yourself” and “how to hang a rope”. Her parents have found a Black, female therapist in the region because they are worried about her wellbeing.

When providing therapy for Tiffany, the therapist might find it helpful to:

  1. Identify risk factors: Tiffany’s risk factors include a history of victimization/bullying by her peers. It is important for the therapist to recognize the racialized/gendered aspect of the discrimination. Tiffany is constantly being dismissed or negatively perceived by authority figures (her teacher and mother). This increases her feelings of isolation and withdrawal. She displays symptoms of depression and her exposure to the internet has provided her with information to make death by suicide a reality.
  2. Affirm her experience. Tiffany’s emotions and experiences are valid. It is important to affirm her experiences because she has been de-valued by her peers, authority figures, and parents. Providing affirmation will build the foundation to work together to create a plan to deal with the factors that influence her suicidality.
  3. Speak truth to her power. The therapist should work with Tiffany and her parents to establish a solid support system and establish health boundaries between the parent-child relationship and provide educational understanding of suicidal behavior. Increasing the parents’ comprehension may address the academic challenges as a cohesive unit. Finding positive outlets of expression may increase Tiffany’s vocalization of her emotions and experiences.

Omar

Omar is a thirteen-year-old who lives in the Bronx with his parents, who are working class and sometimes struggle with finances. Omar has always been perceived as “troubled”. Since a toddler, he has displayed emotional outburst whenever he is frustrated or annoyed. He struggles with academics and continues to display a lack of emotional regulation. When confronted by an authority figure, Omar erupts into explosive outbursts. His teachers classify his behavior as disruptive and aggressive, however he is viewed as a class clown by his classmates. Omar has an extensive history of suspensions and has recently been expelled from his current school due to a physical altercation with a teacher.

At the age of nine, Omar was diagnosed with Oppositional Defiant Disorder (ODD). Omar is very active on social media and follows a politically motivated group that shares information about police brutality and systemic racism in the NYC area. Omar shares with the group his negative experiences with “the system”. On these sites, Omar has been increasingly exposed to visual media of images of Black people being brutalized on camera. These images have psychologically impacted Omar and influence his feelings of isolation and trauma.

Omar has a history of hospitalization due to self-mutilation and suicide attempts. Recently, Omar has been hospitalized after threatening suicide with his father’s handgun. He has been referred by his social worker to a White, male therapist who specializes in suicidal behavior and multicultural therapy.

When providing therapy for Omar, the therapist might find it helpful to:

  1. Identify risk factors: Omar’s history with a mental disorder is something to be considered. However, it is important to be mindful of the delicate balance between providing treatment and safe space for the client. Analyze what you observe from the behavior and confront assumptions that may contribute to systematic biases. Omar’s history of self-mutilation and past suicide attempts are huge red flags. His increased exposure to social media and political engagement may increase his suicidal behavior if not moderated. His proximity to lethal means is also a consideration.
  2. Affirm his experiences. Omar’s therapist should internalize the complexities of Omar’s mental disorder and his subjective experience with racism, classism, and other oppressive categorizations. Individuals who experience mental disorders are not a monolith, so in treating Omar’s suicidal behavior, the therapist should affirm his subjective experiences. What might be presented as symptoms of a mental disorder could be symptoms of discrimination, and vice versa. These things can also be mutually inclusive. It is a complex and delicate balance that a professional needs to navigate. I think that to be effective, all possibilities must be affirmed with the client. The therapist might want to be mindful that while social media and political engagement can be therapeutic, past a certain threshold it can turn counterproductive and unhealthy. Omar’s methods of engagement and the possibility of social media burnout should also be discussed with him. Omar’s complicated history with authority figures should warn the therapist that this relationship must be more mutually inclusive and collaborative to function.
  3. Speak truth to his power. The therapist should work with Omar and his parents to better understand and discuss his mental health including his suicidal behavior. Omar is at a critical stage where he needs a cohesive support system. At this step, a focus is Omar’s emotional regulation and ability of expression. A plan should be created to implement safe spaces where Omar can freely acknowledge his emotional triggers and build confidence in expressing himself. Room should be provided to address the suicidal behavior. As the therapist continues to validate Omar’s experience, discussion can begin on self-care and de-escalation of engagement for Omar’s personal growth.

Tiffany and Omar are examples of the complexities of treating Black youth and express the importance of encompassing a critical theory lens when addressing suicidal behavior among minority groups. To address their suicidality a mental health provider should contextualize the social, cultural, and historical oppositions that they endure. This is their positionality within society. Identify their risk factors. Affirm their experiences. Speak truth to their power.

In Conclusion

There are numerous risk factors impacting the phenomena of suicidal behavior among Black adolescents in the U.S. These internal and external factors possibly underscore the undercurrent of institutionalized racism. Addressing the context of this marginalization may help build the therapeutic relationship between mental health providers and Black clients—extending to the larger Black community.

I appreciate your willingness to journey with me in this series through the complex dynamics of systemic racism and its impact on the suicidality of Black youth. These things are messy and uncomfortable. Yet we must sit with our discomfort and acknowledge the social-historical context of medical biases, racial civil unrest, and political engagement. If we can ask our clients to enter our spaces and share their personal experiences, then it is our responsibility to reciprocate, we can make a difference in this vulnerable population. The mental health of Black children depends on it.

Footnotes:

  1. https://www.apa.org/news/apa/2020/01/black-youth-suicide
  2. https://www.usatoday.com/story/news/education/2019/02/04/black-history-month-february-schools-ap-racism-civil-rights/2748790002/

About the Author

Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

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About Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

A Guide to Contextualizing the Reality of Systemic Racism and Black Suicidology – Part 2: Current Research and Treatments

In Part 1 of this series, we discussed the complex political and historical context of social unrest that influences the growing rates of Black youth suicide. We addressed how systemic racism is an umbrella under which the conditions of Black suicidology, high COVID-19 mortality rates for African Americans, and the current protest against police brutality are interconnected. In conclusion, we highlighted the importance of dismantling marginalization within the mental health system. In this second part of this three-part series, we will examine the current research and evidence-based treatments that address Black suicidology.

In general, death by suicide within the U.S. has continued to significantly increase.1 When examining suicidal patterns by race/ethnicity, suicide rates are lower among African Americans. However, when we take a closer look, suicide among Black adolescents is increasing at an alarming rate.2 The matter of concern is so disturbing that in 2018 a taskforce was pioneered by Representative Bonnie Watson Coleman (D-NJ) and leading experts engineered a bill that will help combat political and mental health factors that influence Black youth suicidology. H.R. 5469: Pursing Equity in Mental Health Act of 2019 has been introduced to the House and referred to the subcommittee of Health. The main objectives of the bill are as follows:

  1. strengthen school-based mental health resources for children and teens,
  2. provide mental health awareness to minorities through community outreach,
  3. address racial and ethnic minority gaps in research, and
  4. address racial disparities in mental health treatment.3

It is immensely important for mental health providers to contextualize the growing trend of suicide among Black adolescents, which does not only encompass suicide, but also factors in self-harm, suicidal ideation, and hospitalization. As we take a comprehensive snapshot of Black suicidology, systematic patterns of marginalization, biases, and inadequacies emerge that contribute to systemic racism.

As I have noted in Part 1, we cannot address Black suicidology without addressing the whole system. The influences of generational poverty, employment biases, housing segregation, environmental racism, and academic disparities play a crucial part in the efficacy of treatment directed at Black communities.

Research on Black Suicidology

Throughout human history, people have been intrigued by the nuances of psychology, including suicidal behavior. The contemporary written literature begins around the late 19th century. Sociologist Émile Durkheim was among the early suicidologists who published his theories. Durkheim theorized suicide as an outcome of social isolation rather than a psychological disfunction.4 Durkheim’s research, primarily a European, male-focused sample, conceptualized suicide as an act exerted by the forces of external factors. This approach neglected the understanding of internal, individualistic behaviors that factor into suicide.

As we transition to more contemporary theories, the paradigm shifts to a greater collective comprehension of individualized behavior. Psychiatrist Aaron Beck centers cognitive behavior within suicidology. He interprets suicide within the framework that individuals with higher degrees of hopelessness—an emotional state referring to negative perceptions of oneself and/or positionality—are tied to more lethal means of suicidality.5 Cognitive Behavioral Therapy (CBT) was created by Beck to treat suicidal clients using a technique that modifies cognitive process. In comparison to Durkheim, Beck’s theory of suicide does address the emotional difficulties linked to psychological disturbances within cognition.

The interpersonal theory of suicide, coined by psychologist Thomas Joiner, conceptualizes suicidal behavior as a complex mental health problem induced by external and internal conflicts, specifically the correlation of:

  1. thwarted belongingness—the psychological necessity of connectedness,
  2. perceived burdensomeness—feelings of exclusion from one’s social group(s), and
  3. capability for suicide—the accessibility to lethal means, increases the desirability for suicide.6

The study of suicide is interdisciplinary and has an extensive philosophical history. However, the magnitude of theory has provided a European, patriarchal lens that centers Whiteness as the default subject. While suicide has been considered a White male problem, the patterns we currently observe stress the importance of integrating the “other”. While we understand that racial/ethnic differences are not attributable to psychological or cognitive differences, social and cultural differences may impact a client’s suicidality.

There is limited literature/research on the phenomenon of African American suicidality. However, suicide research is beginning to be diversified due to the growing attention to Black youth suicide centralized by Black researchers, lawmakers, and mental health professionals.

Another factor in the discrepancies of suicidal research among Black participants is the communal distrust of the mental health field. African Americans, and other minority groups, have historically been subject to unethical, inhumane experiments ranging from scientific racism that naturalizes the inferiority of Black people to forced sterilization. 7,8 In the current state, it is comprehensible and valid that these communities may hesitate to participate in modern research.

Suicide research has contributed to the marginalization of suicidal Black clients by neglecting to examine the complex and unique social/cultural factors that impact Black people experiences. In addition, minorities might be hesitant to participant in studies due to the historical centering of racism within mental health.9

In addressing these concerns, here are a few things to keep in mind when conducting research:

  1. Re-valuate the Research Question.
    If your objective is to study a diverse sample, check that the research question(s) reflects that purpose.
  2. Expand Recruitment Techniques.
    While recruiting participants from university settings (i.e., college campuses, university hospitals) are possibly more convenient, these settings may not be helpful in collecting a more diversified sample. If applicable, think about networking directly with local community clinics, non-profits, religious institutes, and organizations. These groups tend to be the pillars of community engagement and trust.
  3. Integrate Diversity among Researchers.
    Diversifying the scientific community is equally important as including minority participants in research efforts. Providing diversity inclusion within academia is not merely an act of diversity for the sake of diversity, rather providing opportunities for people of color to share their expertise with other professionals within leadership roles.
  4. Highlight the Importance of Research.
    Sometimes scientific jargon is dense, and to the non-scientist can be intimidating. If applicable, highlighting the importance of your study to the participants may be helpful in bridging the trust divide. What is the big picture? Why is this important? Adding the individual, community, and social importance of research integrates a humanistic approach to science.

Treatments for Black Suicidology

In this section, we will discuss the efficacy of two main evidence-based treatments that have been shown to efficiently treat suicidal behavior: CBT and Dialectical Behavioral Therapy (DBT). We will also examine relevance of CAMS as a therapeutic framework in treating Black suicidology.

Cognitive Behavioral Therapy (CBT)
As a cognitive-centered intervention CBT focuses on modifying the mental processes that influence suicidal thoughts. Fundamentally, at its core, CBT is a behavioral modification technique.10 CBT training that directly addresses suicidal cognitions and behaviors have shown to be very effective in treating suicidal clients.11 There is limited information on the efficacy of CBT treatment specific to Black suicidal behavior. The available empirical findings concentrate on depressive disorders, post-traumatic stress disorder (PTSD), and substance abuse. The findings show a mixture of support on integrating multicultural specific interventions.11

Dialectical Behavioral Therapy (DBT)
Dr. Marsha M. Lineman, designed DBT as an evidence-based practice to treat chronically suicidal clients. An off shoot of CBT, DBT is a mindful-based, behavior modifying treatment that centers the client-therapist relationship to alter processes such as emotional regulation and build coping mechanisms.13 DBT has shifted to primarily treat Borderline Personality Disorder (BPD). While there are a multitude of research that supports the efficacy of DBT with BPD clients that express suicidal behavior, the limited literature that discusses African Americans, centers on Black adolescent males diagnosed with Conduct Disorder or display aggressive tendencies.14, 15

The Collaborative Assessment and Management of Suicidality (CAMS)
CAMS is a therapeutic framework that centers on a collaborative, client-focused approach to treating suicidal clients. It is administered with other treatments, and research supports its validity in supplementing suicide-related therapy.16 Research indicates that CAMS has significant potential in multicultural clients, though the efficacy of CAMS Treatment™ on African American suicidology is limited.17

There are a handful of evidence based, suicide-focused treatments. CBT and DBT appear to be highly beneficial to suicidal clients due to their direct modification of suicidal thoughts. The inclusion of client-centered therapeutic frameworks may contribute to increasing support for minority clients. There is a balancing act between sticking to the foundation of these therapies and integrating multicultural awareness.

Based on these possibilities, here are few suggestions to consider when treating Black clients:

  1. Provide Affordable & Accessible Treatment.
    There are not enough treatments accessible and affordable to low-income, disadvantaged communities. Some reasons for this deficiency are due to factors outside of the mental health field. However, they can be addressed through the client-therapist relationship.
  2. Acknowledge Cultural Differences.
    It is essential within the client-therapist relationship to acknowledge the cultural and social disparities that influence the client’s suicidal behavior. As the mental health provider, it is important to not dismiss or ignore their concerns.
  3. Affirm: The Client is the Expert on their Experiences.
    My key ideology when addressing clients is to affirm the expertise of the client. Affirming that their experience is valid is crucial in building trust and rapport.
  4. Establish Space for Black Mental Health Providers.
    As in research, creating a diverse workforce of mental health providers should be normalized. Black therapists are situated in a unique space where they might have an insider understanding on the complex challenges of treating suicide within Black communities.

Conclusion

The study of suicide and suicidal behavior has an extensive history, yet there is a limitation on the understanding of impacts on Black clients. Whiteness has played a central role in our understanding of suicide, but current research illustrates an alarming uptake in suicidal behavior by Black children and teens. In strengthening research and treatment, we must consider our clients’ experiences and the impact of systemic racism on institutions.

In Part 1, we analyzed the context of systemic racism and its psychological toll on Black consciousness. In this Part 2, we reviewed current research and treatment centered on Black suicidology. Now what?  In the comprehensive conclusion to this series, we will address where we go from here with an in-depth look at the necessary measures needed to strengthen treatment for suicidal Black youth.

  1. https://www.cdc.gov/nchs/data/databriefs/db330-h.pdf
  2. https://www.nyu.edu/about/news-publications/news/2019/december/BlackYouthSuicideRatesRising.html
  3. Suicide by Émile Durkheim
  4. https://www.ncbi.nlm.nih.gov/books/NBK223847/
  5. Why do People Die by Suicide by Thomas Joiner
  6. Medical Apartheid by Harriet A. Washington
  7. https://www.smithsonianmag.com/science-nature/disturbing-resilience-scientific-racism-180972243/
  8. Eliminating Race-Based Mental Health Disparities by Dr. Monnica Williams, Dr. Daniel Rosen, & Dr. Johnathan Kanter
  9. https://beckinstitute.org/get-informed/what-is-cognitive-therapy/
  10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4780394/
  11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547560/
  12. https://www.dbtselfhelp.com/DBTinaNutshell.pdf
  13. https://www.sciencedirect.com/science/article/abs/pii/S1359178914000147
  14. https://psycnet.apa.org/fulltext/2014-49443-001.html
  15. Managing Suicidal Risk: A Collaborative Approach by David A. Jobes
  16. Choi, J.L., Rogers, J.R., & Werth Jr, J.L. (2009). Suicide risk assessment with asian american college students: A culturally informed perspective. The Counseling Psychologist, 37, 186-218.

About the Author

Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

See More Articles by this Author

About Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

A Guide to Contextualizing the Reality of Systemic Racism and Black Suicidology

These past months, I have been engulfed in a haze of 24/7 media coverage. It began with the COVID-19 pandemic, filling me with increasing anxiety. The mortality rate for COVID-19 has been disproportionately affecting the African American, Latinx, and Indigenous communities.1 I worried about my family members whose positionality reflects comorbidities, older age, and minority populations. The hospitalization/death of family members and family friends has left me physically exhausted—experiencing insomnia and feeling mentally drained. I was still glued to the television when the recorded murder of George Floyd literally ignited America.

We Black professionals have learned how to master navigating through the murky waters of microaggressions and institutionalized oppression. Over a duration, I thought the clout of respectability politics – the discourse that professional minorities can rise above racism due to their professional status – would shield me from this. I was wrong. I have awakened, this week, with a complete comprehension of my positionality as a mental health professional, and a clear understanding of the context of suicide among Black Americans.

This article, the first in a series, is written with the objective of examining the social-political context of Black suicidology. We will examine the historical catalyst that has created the “perfect storm” of racial civil unrest and trauma within the Black community. The main goal is to understand how this impacts the growing trend of suicide among Black youth.2

Psychological Theories on Black Suicide

Postulated by Dr. Joy Degruy, the theory of Post-traumatic Slave Syndrome asserts that chattel slavery (which allowed people — considered legal property — to be bought, sold, and owned forever) left a legacy of intergenerational, psychological trauma on the descendants of enslaved Africans.3 It is represented in the current mental health crisis and racial disparities that we observe today. Another theorist, psychiatrist Dr. Alvin Poussaint, elaborates that the stigmatization of depression/suicide within the Black community, compounded with the minimalization of the mental health crisis by mental health professionals, constructs the current rise in suicide among Black boys and men.4 These scholars argue that suicide is a symptom of a larger trauma that Black people endure.

To enhance our comprehension of these theories, let us visualize the traumatic stress of the Black community in comparison to a rubber band. A moderate amount of stress, which is a natural reaction to stimuli within our environment, is intrinsically linked to our survival. Similarly, a rubber band is engineered to be elastic and handle a moderate amount of stress and tension. However, when too much force is exerted, without any release, the rubber band will snap.

In recent years, suicidal behavior among Black youth has significantly increased.5 As experts across a multitude of specialties continue to work in understanding the methodology behind this trend, we can look to previous and current events to paint a snapshot of what in the world is happening. In my opinion, the vicarious trauma experienced by the Black collective – because of repeated exposure to stress – has cultivated the internal and external stress that is currently present.

This stress is not random nor coincidental; it is systemic. African Americans have been funneled through imperialism, the trans-Atlantic slave trade, chattel slavery, Jim Crow, the Civil Rights Movement, and a “post-racial” America. In between these defining moments, space has not been created to holistically heal and breathe.

The COVID-19 pandemic, which disproportionately impacts African Americans, has increased these tensions. African Americans mostly reside in densely populated cities. Their homes are often intergenerational and contain extended family. They are more likely to lack medical/mental health resources, preventive care, are overrepresented in the prison system, are essential/critical workers, have little to no sick time, and work under horrible working conditions. 6

These stresses are heightened by the political racial divide that has resurfaced as a result of the killings of Ahmaud Aubrey, Breonna Taylor, and George Floyd. The global protest we are witnessing in this historical era is directed at police brutality. Within their lifetimes, Black boys and men are at the highest risk of being killed by police than any other racial group.7

The Role of Social Media

I think it is important to also understand the role social media plays in all of this. On one hand, it serves as a platform to facilitate the quick distribution of information to a large mass of individuals. This helps to circulate instances of police brutality and other discriminations to the masses, which helps mobilize movements within activism.

On the other hand, the lack of filtering violence has repeatedly exposed adolescents to images of brutalized Black bodies. You can easily find, as you scroll through your social media feed, at least one if not several uncensored videos or images of Black traumatization. For Generation Z, where technology and social media are embedded in their daily lives, these images may have adverse effects.

How does the repeated exposure to these images influence the psyche of Black youth? Does it correlate with or contribute to the increased suicidal behavior among Black youth? The present pandemic and police brutality together cultivate the conditions for a global protest and increase mental health dysfunctions that are currently apparent. Comparable to the upward trend of Black youth suicide, the disproportionate mortality rate of COVID-19 and police brutality may be linked to the systemic overlap of marginalization.

Connecting Systemic Racism to Black Youth Suicide

What does this all have to do with Black youth suicide? Black suicidology does not exist within a vacuum. It is situational and framed by a multitude of factors. Therefore, it is important to contextualize the collective experience. And in a society with a history of racial division, we cannot separate the system from the context. The growing trend of suicide among Black youth is a symptom of systemic racism and the systematic marginalization of Black experiences.

For example, a recent study documented that several White doctors hold racial beliefs that “Black people have physically tougher skin” and “have a higher pain threshold than White patients”.7 Perceived racial biases such as these contribute to the systematic mistreatment of Black people by the medical field. Black women have a maternal mortality rate that is three times higher than White women. ADHD Black youth are often underdiagnosed or misdiagnosed with Oppositional Defiant Disorder (ODD).9

Although Black youth are the fastest growing group within adolescents for suicidal behavior, Black people are underrepresented in suicide-related research and treatment, and as mental health professionals. The patterns that we are observing are conditioned upon institutionalized racism. How do we address Black suicide without acknowledging the whole system?

It is like a hive of hornets have built a nest in your attic, and instead of removing the whole nest, you spend your days and nights shooing away the hornets around you. The underlying causes of the problem persist.

The Role of Mental Health Professionals

The Black mental health crisis is a residual effect of a system that needs reforming. This state of emergency has been afire for over four-hundred years. What steps can we in the mental health field take to increase the efficacy of treatment for Black suicidal behavior?

When we address Black suicidology, it is essential to address the impact of racism on our clients’ experiences. It is essential to evaluate institutionalized oppression holistically – meaning, examine how housing, financial, economic, environmental, and other social factors directly impact your client. As we address and acknowledge systemic oppression, we as mental health professionals must strive to understand the whole picture.

I think that as mental health professionals it is our responsibility to acknowledge and strive to understand and act upon the uniqueness of the Black life experience. I conclude that there are five main components in reforming the ways we deal with racial disparities within Black suicidology.

  1. Provide more inclusive research. As with research in general, the general body of suicide research currently focuses on Whiteness. We need to fund more research tailored to addressing the unique experiences of Black people. We cannot be under the assumption that research impacts people of color similarly to Whites. It is essential to acknowledge and address how cultural/social differences should effect specialized nuances in assessment and treatment methodology.
  2. Integrate the community. The survival of Black America is built on community, family structure, and the church. To address suicide, we must meet clients where they are. As CAMS and other effective treatments understand, the individual is the expert on their own experience. People know what they need, and it is our objective to provide them with the tools and terminology for their mental health. For example, many in the Black community may describe suicidal behavior as a manifestation of physical pain (ex., “I’m feeling pain in my stomach” or “my head hurts”) or as a symptom of “strange” behavior (i.e., “my child is being lazy” or “her behavior has been changed”). Mental health professionals not versed in these cultural differences may dismiss, overlook, and misdiagnose their clients.
  3. Introduce accessible mental health services. Accessibility refers to providing services in communities of color and services that are affordable. We have discussed the political and social disparities that make accessible mental health services difficult. Accessibility is crucial in the struggle to combat suicide in the Black community.
  4. Fund evidence-based treatments that support multicultural therapy. There is limited research on the efficacy of treatments/therapies directed specifically towards Black trauma and suicide. We are not fully adept at understanding what works; however, of the literature available, treatments that are multicultural in nature are most effective with this community. Multicultural treatments integrate a collaborative (client-led) and community-centered approach.
  5. Educate and hire more Black mental health providers. Due to a history of medical/mental health racism, there is distrust of the mental health field by Black people.11 Is it fair to expect marginalized people to freely interact with a system they perceive to be oppressive? Instead, it is more beneficial to validate and empathize with our clients, and Black mental health providers are most inherently suited for this. Therefore, we need more Black mental health professionals who more likely possess an acute understanding of the lived experiences of those they are treating.

Next Steps

We are experiencing a shift in the American conscious. As Black Americans continue to deal with stressors of racism, mental health services are a necessity.

What is our responsibility in providing preventive measures and intervention to this community during these extraordinary times? How do we continue to address the growing trend of suicidal behavior among Black youth? What is our responsibility as mental health providers in comprehending the pain of our clients, colleagues, and students?

These questions form the basis of conversations that need to happen in our field, but it starts with acknowledging the reality of systemic racism, the impact of institutionalized marginalization and racial disparities, and the psychological toll it takes to survive.

References:

  1. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html
  2. Degruy, Joy. (2005). Post traumatic slave syndrome: America’s legacy of enduring injury and healing. Milwaukie, Oregon: Upton Press.
  3. https://www.npr.org/templates/story/story.php?storyId=5070636
  4. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html
  5. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html
  6. https://www.pnas.org/content/116/34/16793
  7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/

About the Author

Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

See More Articles by this Author

About Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

Self-Determination Theory (SDT) and the CAMS Framework® of Evidence-Based Suicide Prevention

Posted on by erics

I was recently reviewing some literature for a current study and happened to come across a newly published conceptual article by a scholar named Édua Holmström, who is at the University of Helsinki in Finland. The article was a marvel to me as Holmström’s paper uses the “Self Determination Theory” (SDT) to conceptually explain how the CAMS Framework of suicide prevention motivates suicidal individuals to choose life.

The Power of CAMS

Those who use the CAMS framework with suicidal patients already know that it first and foremost is based on empathy & honesty, and encourages your clients to work collaboratively with you to develop their unique suicide-focused treatment plans. This paper shines a light on this important element of the CAMS approach to treatment, and theorizes that this autonomy and acknowledgment of the client’s ability to make decisions about their own treatment plan is the key to the effectiveness of CAMS to clinically help save lives.

Applying Self-Determination Theory to CAMS

It turns out that SDT elegantly describes certain key aspects of this spirit and embodies the essence of doing CAMS as a collaborative and empathic therapeutic patient-centered framework. Within CAMS there is a clear and overt emphasis on respecting and validating the suicidal patient’s autonomy, a central construct within SDT. Writing about CAMS, Holmström notes “…many suicidal individuals make informed decisions about treatment with the support of an empathetic clinician.”

I could not agree more. And it is exhilarating to read the reflections of an unmet scholar in a faraway land applying a novel theory (at least to me) as explanatory for this evidence-based approach to suicide intervention that has consumed me over my entire professional career. Even after 35+ years in the field I cannot begin to describe the unabashed excitement I felt discovering this beautifully written paper about something that is so near and dear to my life’s work, and it got me thinking…

I often say to my students, “There are no new ideas, just repackaged old ones that capture enduring truths.” Over the years I have heard variations on this notion as it relates to CAMS. A seasoned and savvy inpatient nurse during a training session once told me that CAMS was nothing new, it was simply good nursing! She was delighted when I agreed and shared that I began my professional career on inpatient nursing staff as a psych tech. Her response? Of course, you did, I knew it! Some years later I had a similar conversation with a sophisticated clinical social worker who insisted that the essence of CAMS was merely doing good clinical social work!

Over decades I have come to relish many such conversations with clinicians across disciplines who have said in some way or another that they have been “doing CAMS” for years without realizing it. I think of my friend Kevin Briggs, who was a CHiPS highway patrolman for many years. His beat was the Golden Gate Bridge, and in his book, Guardian of the Golden Gate Bridge, Kevin recounts incredible experiences of talking suicidal of people out of jumping to their deaths from the iconic bridge. He could not save them all, but he literally did help save hundreds of lives. Over coffee, Kevin once told me that he used to lie down on the pavement to be at the same level with certain prospective jumpers sitting on a pipe on the other side of the railing so he could talk to them at their level. He asked me: So, was I doing CAMS? My response: Kevin, you are a natural!

Benefits of Evidence-Based Treatment

Many of my days are consumed with randomized controlled trials (RCTs), interpreting data, and writing scientific papers in my determined effort to prove that CAMS works through replicated RCTs with the highest rigor of science possible. It is my passion and my goal to well establish a solid place for CAMS within systems of care as a means of clinically saving lives for people on the brink of life.

But when I read this article from a faraway land explaining to me how my intervention works, it gave me pause to think. I reflected on many conversations over decades with clinicians about how to help save lives. And I reflected on some simple and enduring truths about life. Most people want to live a life with purpose and meaning; most do not desire death by suicide. But for those who do, simple ideas about autonomy, empathy, collaboration, and truth go a long way toward creating the possibility of saving a life, even in the face of suicidal despair. “Good nursing” or “good social work” can help transform lives and help people self-determine whether they live or die.

It is gratifying and humbling to see an outside source confirming the importance of self-determination concepts as potential cornerstones of CAMS.

Malpractice Liability Related to Suicidal Risk: How to Decrease the Risk

Few clinical concerns frighten mental health providers more than the fear of being sued for malpractice related to working with suicidal patients.

In my professional life, I routinely train clinicians across the spectrum of mental health care. Over the past thirty years, I have trained thousand of mental health providers who practice in virtually all disciplines and treatment settings. As an Associate Director of Clinical Training in an APA-accredited clinical psychology training program, I have had countless opportunities to discuss the topic of suicide risk assessment and treatment with aspiring mental health providers. In all my years of teaching, training, supervising, and consulting, I have been struck by the concern that seemingly affects all types of mental health providers: the fear of malpractice liability pertaining to clinical work with suicidal patients.

Mental Health Providers Want to Know “How Do I Not Get Sued?”

Recently, I presented at a psychiatric grand rounds at a prestigious medical center. As often is the case with such engagements, I had a series of meetings with young mental health providers at this facility – psychologists, clinical social workers, and psychiatrists. In one meeting, I was introduced to a group of young providers, and they were invited to ask me “anything under the sun” about clinical work and suicide risk. After going around the room, the single most pressing question, by far, was, “How do I not get sued if a patient of mine takes their life?” We had an hour to talk about any topic related to clinical suicide prevention, and yet we spent fifty minutes talking about how to avoid getting sued.

This example underscores perhaps the most problematic aspect of the fear of malpractice liability related to treating suicidal patients. Namely, that mental health clinicians can easily become preoccupied with the perceived threat of malpractice and thus resort to defensive practices. In adopting a defensive posture, one may come to see the suicidal patient as a threat to one’s professional livelihood. Within this dynamic, the patient (and potentially the patient’s family) may seem like the enemy—an adversary who is ready and eager to sue if treatment goes south.

Fatal Suicide Outcomes Are Often Viewed as Malpractice

Early survey data has shown that when there’s a fatal suicide outcome of someone engaged in mental health care, the majority of family members studied considered the death of their loved one as an obvious case of malpractice. Indeed, within this survey, 25% of family members of people who had died by suicide contacted an attorney to pursue litigation for malpractice.

Reflecting on the topic of mental health provider malpractice, it is interesting to note that, within our culture, there is not the same routine presumption of negligent liability with other fatal outcomes following health care treatment. Certainly, with egregious examples, malpractice litigation is considered (e.g. a surgical procedure in which a surgical tool is left in the body). But despite the fact that we live in a highly litigious society, malpractice lawsuits are not routinely considered across health care delivery as they are in cases of suicide. There is one notable exception: Fatalities in childbirth that occur during delivery also often prompt the assumption of negligent malpractice. As a society, apparently, there is little tolerance for care that fails to prevent a self-inflicted death or the loss of an infant during childbirth. Even if the care provided was competent or heroic, a lawsuit might well be considered and pursued.

Fear of Malpractice Can Change the Way You Practice

In describing the topic of malpractice liability, I do so in full recognition that any death is a personal and family tragedy. But the concern that I am presently raising is how the fear of malpractice litigation can potentially paralyze an otherwise conscientious provider – leading to the proverbial deer in headlights. Such paralysis can lead to defensive practices in mental health care that might decrease the apparent exposure to malpractice risk but may have little to do with what is actually in the patient’s best interest.

As I have written about elsewhere, defensive practices within mental health can often lead to the overuse of inpatient psychiatric hospitalizations. Because of fear of malpractice, this type of “better safe than sorry” rationale often comes into play for patients who do not necessarily need this level of intensive intervention. In addition, there is often an overreliance – even a kind of wishful thinking – related to prescribing psychotropic medications to treat underlying psychiatric disorders of suicidal people. Despite the fact that the literature supporting the use of medicine to treat suicidality is limited or mixed at best, malpractice-related concerns may compel pursuing options that are extreme or ineffective.

If defensive practice is not the best way to avoid a malpractice suit, what is?

Definition of Malpractice in Mental Health Care

The answer to this question lies in understanding what constitutes malpractice. Briefly, malpractice is a tort action wherein a plaintiff (typically a surviving family member of someone who has died by suicide) engages a lawyer to argue that the defendant (the mental health provider) insufficiently met the “standard of care” and that what the provider did or did not do was a direct or proximate cause of the fatal outcome.

The standard of care for mental health providers is defined on a case-by-case basis by expert witnesses who attest to what a similarly trained clinician (with a similar case and in a similar setting) would do. An expert witness is hired by the plaintiff’s attorney to argue that the defendant did not meet this standard of care. The burden of proof lies with the plaintiff. In turn, the defendant’s lawyer hires their expert witness who argues that the mental health provider actually did meet the standard of care.

What ensues is an unpleasant process of discovery of records and relevant documentation, interrogatories, and depositions of the major parties within the case. Many, if not most, malpractice cases do not make it to trial—they get dropped or settled—yet the process of litigation can be traumatic for the defendant.

How to Decrease Your Potential Exposure to Suicide-related Malpractice Liability

More than twenty-five years ago, I published a journal article about how mental health providers can decrease their exposure to malpractice liability related to suicide. The glib answer was, and is, to save every suicidal patient! In reality, tragically, this is not always possible.

What one can do, however, is provide the best possible care, which is both suicide-specific and well-documented. This can be readily accomplish in your routine clinical practice by developing and adhering to “usual and customary practices” that focus on four key pillars of competent clinical care for suicidal patients.

These key pillars are:
1) Routinely and thoroughly assess for suicidal risk, and document that risk within the ongoing medical record.
2) If your patient is suicidal, there should be a sufficient focus on suicidality within the treatment plan, the use of a stabilization plan, and ongoing discussions about lethal-means safety.
3) As a competent mental health provider, you cannot “drop the ball” on the topic of suicide within the ongoing course of care. This means that the issue of suicide should be routinely assessed, treated, and well-documented.
4) You need to seek consultation on cases of potential suicide and document the consultative input.

Fatal suicide outcomes in mental health care are difficult for everyone involved, including families, providers, and organizations. But such outcomes are not necessarily legitimate grounds for malpractice litigation. There is no guarantee that by following these relatively simple steps, you will not be sued in the event of a fatal suicide outcome. But such routine practices can reduce one’s risk of malpractice exposure to negligible levels. This is because plaintiff attorneys take malpractices cases on contingency, which means they do not make a great deal of money unless they win or settle the case.

Skip Simpson, one of the nation’s leading plaintiff attorneys, has noted that if mental health providers follow the steps listed above and diligently document their practices, there is little incentive for malpractice lawyers to pursue litigation. Why? Because if a provider does follow these steps, the central litigation question becomes: Where was the negligence? Mental health providers are not expected to be mind readers or miracle workers, with unlimited control over the behaviors of their patients. But they are expected to be competent and to meet or exceed the standard of care.

CAMS Integrates “Competent Care” into All Clinical Care

While mental health providers can readily follow the recommended steps described above, the use of CAMS ensures that these basic steps of competent care are “baked” into their clinical care practices. CAMS, which stands for “Collaborative Assessment and Management of Suicidality,” is an evidence-based approach for the assessment and treatment of suicidal risk.

While I have seen cases in which patients who received CAMS-guided care have died by suicide, I have never seen or heard of a successful case of malpractice against a provider who adherently used CAMS. I have in fact seen on a few occasions that the use of CAMS has directly discouraged the pursuit of malpractice litigation. More to the point, I have directly seen or heard about countless cases in which CAMS successfully helped suicidal patients walk back from the brink of self-destruction.

Within CAMS-care, all of the members of our team are dedicated to reliably providing the best possible mental health care for patients at risk of suicide. In most cases, that will result in saving a life and averting the hardship that befalls families—and providers—who lose someone to suicide.

About the Author

David A. Jobes Ph.D. ABPP

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.

See More Articles by this Author

About David A. Jobes Ph.D. ABPP

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.

Best Practices in Care Transitions for Individuals with Suicide Risk

Research indicates that suicide risk following inpatient psychiatric care is 300X higher in the first week and 200X higher in the first month than the general population. In the National Action Alliance for Suicide Prevention’s new guide for best practices in care transitions from inpatient to outpatient care, CAMS is recommended in the critical step for inpatient providers to connect with an outpatient provider prior to your patient’s discharge. The Guide notes that the transition from inpatient to outpatient behavior health care is a critical time for patients with a history of suicide risk. Implementing a series of best practices both prior to, and after discharge, will help keep patients safe during the care transition period.

Download the report from Action Alliance

The Importance of Acknowledging Cultural Differences and Validating the Experiences of Suicidal Minorities

One thing on which the United States of America prides itself is its foundation in and status as a “melting pot”, welcoming people of all races to our shores – and the USA is not unique in this way. All around our world, our communities encompass a colorful palette of races and social cultures, each with many unique collective experiences and perspectives.

These distinctive cultures make up many minority sets that have each developed their own cultural identities that differ (sometimes drastically) from “the norm”.

In our work with suicidal members of these communities, it may be tempting to gloss over these differences – especially if they make us uncomfortable. Furthermore, we’re often encouraged in society to practice “color blindness” in order to treat everyone equally and avoid any possibility of appearing racist, homophobic, politically incorrect, out of touch, or any other undesired label.

However, sweeping cultural differences under the rug and ignoring the unique experiences of suicidal minority patients undermines our ability to connect with our clients and build trust.

Acknowledging Cultural Differences

Instead of overlooking the cultural identities of suicidal ideators that differ from our own, acknowledging those differences – and even seeking to understand them – demonstrates interest in them as valid human beings and helps to build trust.

A few examples of how to acknowledge cultural differences with patients might include:

  • “Is that common to your culture? How does that work normally?”
  • “Hmm… now that’s a term I’m not familiar with. Can you explain it to me?”
  • “Ah, I didn’t know that. I’m glad to learn something new about your culture.”

Showing interest in culture and seeking to understand its inner workings and perspectives not only helps to foster rapport and trust, it may also help some clients better understand their own circumstances and how to incorporate those differences into a plan for reducing suicidal thoughts in their lives.

Validating Experiences

Equally important to acknowledging cultural differences is to affirm the validity of their unique experiences and feelings as a member of their minority. Validation does not simply mean that you understand or agree – it is the act of letting your clients know that you acknowledge, recognize, and support their experiences.

For example:

  • “I can tell that you’re uncomfortable talking about this, and that’s perfectly normal. It’s not easy to share sensitive things like this, but I want to understand your feelings. Can you keep going?”
  • “I can understand how being the only transgender person in your small town made you feel very alone and scared. I guess I would feel that way, too.”
  • “I imagine that can’t be very easy to deal with. Can you share more about how that makes you feel when that happens?”

It’s not always easy to talk about deeply personal experiences with a therapist, so be sure to thank the person for sharing with you.

Incorporating these two practices into therapeutic sessions will go a long way in establishing trust and building rapport with our suicidal minority clients.

For more information

To learn more about effective methods for working with suicidal minorities, read “5 Effective Approaches When Working with Minority Clients” by Tanisha Esperanza Jarvis, M.A.

About the Author

Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

See More Articles by this Author

About Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

An Exploration of Future Research and Treatment to Combat the Crisis of Black Youth Suicide in America

While the American public was preparing for the Holiday season, on December 17, 2019 Rep. Bonnie Watson (D-NJ) introduced a bill to U.S. House of Representatives.1 H.R. 5469, or more commonly known as the “Pursing Equity in Mental Health Act of 2019”, proposes to allocate funding to organizations to address mental health problems among youth of color. This bill specifically pertains to addressing the epidemic of suicide among Black adolescents. In the early months of 2019, an emergency taskforce was formed by the Congressional Black Caucus (CBC), which included research findings that were based on the collective work of Black professionals within numerous fields of expertise.

The report states that suicide is the second leading cause of death among Black adolescents between the ages of 10-19.2 The report further states that Black youth disproportionately die by suicide at higher rates than other races/ethnicities. In the last decade, suicide rates for Black adolescents have increased by 73%.3 Contrary to the trends we observe with Black adolescents, current research finds that the suicide rates among Black adults are relatively low in comparison to White counterparts.4

Focus of the Pursuing Equity in Mental Health Act

The Pursuing Equity in Mental Health Act of 2019 aims to:

  • Increase research on the risk factors, preventative factors, and methodology of suicide within Black youth, and
  • Support organizations focused on providing holistic, mental health treatment.

The current literature of research tackling the suicidology of Black adolescents is minimal. An explanation for this conundrum may be explained by implicit bias within research. The congressional report mentions a study that found that Black researchers are denied funding 10x the rate of White researchers.11 There is a necessity for research and treatment concentrated on the alarming trend of suicide among Black youth.

Based on my research with CAMS (Collaborative Assessment and Management of Suicidality), my research interest aligns with examining suicidal behavior within marginalized individuals (i.e., racial/ethnic, gender, and sexual minorities). In this article, I provide suggestions for the allocation of future research, treatment, and interventions supported by the proposed bill.

But first, why do we observe this alarming trend among Black youth? There are a few risk factors that influence suicide and suicidal behavior among this demographic.

Risk Factors

Trauma & Social Media

The image of a dead or injured Black body flashes across the screen of a personal computer or smartphone.

While scrolling through any of multiple, popular social media sites, a teenager may view dozens of these images. In the age of technology, sharing information across platforms is instant, and unfiltered. Whether accurate or appropriate, the information is available.

This increased exposure to graphic images shared among social media has been shown to increase depression and suicide among adolescents.5,6 In addition, other psycho-social stressors such as SES, academic opportunities, and systematic marginalization may contribute to suicidal behaviors among black adolescents. 7

LGBTQ+ Identity

Individuals who identify as LGBTQ+ experience higher rates of suicidal behavior than other groups. 8 Association of this risk factor is often linked to bullying, lack of social acceptance, and heightened occurrence of homelessness. These trends are evident across race/ethnicity and age.

Implicit Bias and Stigma

There is a history of mistrust and bias that permeates the therapeutic relationship between the African American community and a “white” mental health field, stemming from the origins of racist pseudo-science and unethical experimentation.9 This is among several reasons Black people are often reluctant to seek mental health support. Another factor that may contribute to an increase in suicidal behavior among Black youth is perceived social stigma. Black adolescents with mental illness experience stigmatization from family, communities, and the larger society.10

Future Research and Treatment

It is appropriate for allocations of funding to go towards organizations/individuals who are already working with suicidal Black youth. These individuals would already have established rapport within the community and possess advance knowledge on implementing research and providing support. By focusing attention on the existing expertise within this area, we help to lessen the “learning curve” and improve training towards other professionals who have Black clientele.

There are a multitude of established literature on the effectiveness of treatments for suicidal individuals. When working with marginalized groups, it is important to incorporate what works. Why fix what is not broken? Just adapt.

Research has shown that Cognitive Behavioral Therapy (CBT) and Dialectic Behavioral Therapy (DBT) are effective in treating suicidal behaviors.12,13 Furthermore, research also highlights the effectiveness of CAMS as a therapeutic framework.14 What makes these treatments work? The use of client-focused therapy and incorporation of holistic methods (e.g., collaborative approach, community engagement, cultural inclusion, etc.) are the foundations that stabilize these interventions.

A CAMS Hypothetical Randomized Control Trial (RCT)

The efficacy of CAMS was initially measured using RCTs. Suicidal clients (whether recruited through outpatient centers, universities, etc.) were split into a treatment as usual (TAU) group in comparison to the CAMS administered group.15 The Suicide Status Form (SSF) was used as a guide to administer CAMS between the clinician and client. The TAU and CAMS groups were compared after the initial and consecutive sessions.

A similar design could be applied when using an RCT to compare TAU with CAMS in a sample of Black adolescents with a history of suicidal behavior. These participants possibly could be recruited from outpatient centers, counseling centers on college campuses, middle school and high school programs, and through other organizations. Of course, these individuals must meet the requirements of race/ethnicity and a history of suicidal behavior and/or mental health.

Based on previous CAMS RCT research, a hypothetical study is outlined in the flowchart below:


Figure. A flowchart depicting an RCT examining the efficacy of CAMS treatment within a sample of suicidal Black adolescents.

Conclusion

If the Pursuing Equity in Mental Health Act of 2019 is passed into legislation, it will be a milestone for research and treatment of suicidology within Black adolescents. The rising trend of suicide among this group rings warning signs, which call to action experts who provide an interdisciplinary lens to research and treatment.

More extensive and intense research into the risk and preventative factors of suicide among Black youth may begin to tackle a stressor of systematic marginalization. Implementing more efficient mental health treatment specifically designed for this demographic may provide holistic and cost-effective interventions.

As I continue my work as a Black researcher and clinician, I am discovering that integrating a client-focused, community-centered, and culturally inclusive approach into therapy/research is the difference between life and death for our clients.

  1. References World Health Organization. Suicide Rates (Per 100,000 Population); World Health Organization: Geneva, Switzerland, 2019.
  2. U.S. House of Representatives, Emergency Taskforce on Black Youth Suicide and Mental Health. (2019). Ring the Alarm: The Crisis of Black Youth Suicide in America. Retrieved from https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf
  3. Runcie, A. (2019, December 17). Proposed legislation attempts to address rising suicide rates among black children. CBS News. Retrieved from https://www.cbsnews.com/news/proposed-legislation-attempts-to-address-rising-suicide-rates-among-black-children-2019-12-17/
  4. Leong, F. T. L., Nagayama Hall, G. C., McLoyd, V. C., & Trimble, J. E. (Eds.). (2014). APA handbook of multicultural psychology (Vols 1 & 2). Washington, DC: American Psychological Association.
  5. Twenge, J.M., Joiner, T.E., Rogers, M.L., & Martin, G.N. (2017). Increases in depressive symptoms, suicide-related outcomes, and suicide rates among u.s. adolescents after 2010 and links to increased new media screen time. Clinical Psychology Science, 6, 3-17.
  6. Feuer, V., & Havens, J. (2017). Teen suicide: Fanning the flames of a public health crisis. Journal of the American Academy of Child & Adolescent Psychiatry, 56, 723-724.
  7. Hope, E.C., Hoggard, L.S., & Thomas, A. (2015). Emerging into adulthood in the face of racial discrimination: Physiological, psychological, and sociopolitical consequences for african american youth. Transitional Issues in Psychological Science, 1, 342-351.
  8. Pritchard, E.D. (2013). For colored kids who committed suicide, our outrage isn’t enough: Queer youth of color, bullying, and the discursive limits of identity and safety. Harvard Educational Review, 83, 320-345.
  9. Washington, H.A. (2006). Medical apartheid: The dark history of medical experimentation on black americans from colonial times to the present. New York, NY: Doubleday.
  10. Rose, T., Joe, S., & Lindsey, M. (2011). Perceived stigma and depression among black adolescents in outpatient treatment. Children and Youth Services Review, 33, 161-166.
  11. U.S. House of Representatives, Emergency Taskforce on Black Youth Suicide and Mental Health. (2019). Ring the Alarm: The Crisis of Black Youth Suicide in America. Retrieved from https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf
  12. Stanley, B., Brown, G., Brent, D.A., Wells, K., Poling, K., Curry, J., …Hughes, J. (2009). Cognitive-Behavioral therapy for suicide (cbt-sp): Treatment model, feasibility, and acceptability. Journal of the American Academy of Child & Adolescent Psychiatry, 48, 1005-1013.
  13. Ougrin, D., Tranah, T., Stahl, D., Moran, P., & Rosenbaum, A. (2014). Therapeutic interventions for suicide attempts and self-harm in adolescents: Systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 54, 97-107.
  14. Jobes, D.A., Moore, M.M., & O’Connor, S.S. (2007). Working with suicidal clients using the collaborative assessment and management of suicidality (cams). Journal of Mental Health Counseling, 29, 283-300.
  15. Jobes, D.A., Au, J.S., & Siegelman, A. (2015). Psychological approaches to suicide treatment and prevention. Curr Treat Options Psychiatry, 2, 363-370.
For more information

To learn more about effective methods for working with suicidal minorities, read “5 Effective Approaches When Working with Minority Clients” by Tanisha Esperanza Jarvis, M.A.

About the Author

Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.

See More Articles by this Author

About Tanisha Esperanza Jarvis M.A.

Tanisha Esperanza Jarvis M.A.
Tanisha Esperanza Jarvis received her B.A. in anthropology and sociology at Spelman College in 2015, where she also minored in Comparative Women’s Studies. While at Spelman, her research focused on integrating academia and social justice. As a Bonner Scholar and Social Justice Fellow her research work included preventative and interventional treatment of sexual trauma and LGBTQ and racial/ethnic minority research. She finished her M.A. in psychological sciences from The Catholic University of America (CUA) in 2019. Her research within the Suicide Prevention Lab (SPL) focused on integrating an international approach to CAMS research and treatment of suicidality within marginalized communities.