Who You Treat: Adults

Lethal Means Safety and CAMS

Posted on by erics

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

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

Understanding Lethal Means Safety

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

The Nuances of Lethal Means Interventions

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

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

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

Effective Lethal Means Safety Interventions

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

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

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

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

The CAMS Evidence-Based Approach to Lethal Means Safety

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

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

Unconventional Care Saves Lives

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

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

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

404 ERROR: Mistakes We Need to Stop Making in Suicidology On-Demand

Rates of death from heart disease, stroke, drunk driving, homicide, and other public health problems have fallen substantially. Yet, suicide deaths have not declined. Why is suicidology not doing better? In this webinar I suggest that we overvalue predicting suicide — so much so that we mistakenly treat prediction as synonymous with understanding and preventing suicide. In reality, highly accurate real-world prediction is a) neither sufficient nor necessary for suicide prevention, b) impossible to achieve, and c) an inappropriate basis for developing and validating suicide theory. These claims may sound counterintuitive, but they reflect common knowledge and practice in other fields of health and science. If we want to make progress, suicidology must correct these mistakes, and adjust suicide research and prevention efforts accordingly.

Dr. E. David Klonsky

About Dr. E. David Klonsky

E. David Klonsky, PhD, is Professor of Psychology at the University of British Columbia. He has more than 100 publications on suicide, self-injury, and related topics, and his contributions have been recognized by awards from the American Association of Suicidology, Association for Psychological Science, and Society of Clinical Psychology (APA). He is Past-President of the International Society for the Study of Self-injury, Associate Editor of Suicide and Life-Threatening Behavior, and has advised the American Psychiatric Association for DSM-5 and both the US and Canadian governments regarding suicide and self-injury prevention. In 2015 he published the Three-Step Theory (3ST) of suicide.

Watch the Recorded Webinar On-Demand

Enter your information to gain access.

  • This field is for validation purposes and should be left unchanged.
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form

The NEED for Competence and Confidence

Posted on by erics

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Suicide Prevention in Healthcare Settings On-Demand

Recent survey data from SAMHSA indicates that there are 12 million American adults that thought seriously about suicide in 2019. Many people who are suicidal end up in emergency departments or are hospitalized in part because clinicians may not be confident in their ability to effectively treat them and may resort to defensive practices (e.g., potentially unnecessary hospitalizations) fearing malpractice liability. As part of Project 2025, AFSP is focusing on reducing suicide deaths in relation to emergency department and healthcare system engagement. Christine Moutier, M.D., AFSP’s Chief Medical Officer, David Jobes, Ph.D., professor and creator of CAMS, and Ms. Diana Cortez Yanez, a leading voice from the lived-experience perspective, will team up to discuss current systems of care along with evidence-based best practices for optimal clinical suicide prevention.

Topics will include:

  • use of evidence-based assessments
  • treatments
  • the use of medications
  • decreasing malpractice risk through sound clinical practices

The goal is to raise awareness about effective clinical care for suicide risk and the importance of creating lives worth living.

Watch the Recorded Webinar On-Demand

Enter your information to gain access.

  • This field is for validation purposes and should be left unchanged.
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form

On-Demand: Providing Effective, Risk Managed Treatment for Potentially Suicidal Patients in Outpatient Private Practice

CAMS-care has partnered with The Trust and TrustPARMA to offer this free webinar as a way for psychologists to build awareness about using an evidence-based, suicide-focused treatment for suicidal patients. Our experts will explore the issues psychologists face and how to address licensing boards and angry clients. They’ll also look at the prevalence of suicidal ideation and why training more clinicians in evidence-based treatment is paramount to reducing the national suicide rate.

They’ll detail the magnitude of suicide rates in America, screening and assessment best practices to determine when to hospitalize a suicidal patient and the considerations for treating patients in an outpatient clinical setting. There will be an overview of evidence-based treatments (DBT, CT-SP, BCBT, and CAMS), systems of care, why psychologists will continue to play a vital role, using the Suicide Status Form (SSF) as a clinical roadmap, and much more.

Dr. Eric A. Harris

About Dr. Eric A. Harris

Dr. Harris is a licensed psychologist and attorney in Massachusetts. Dr. Harris received his J.D. from Harvard Law School and his Ed.D. in Clinical Psychology and Public Practice from the Harvard University School of Education. He was the initiator of the Trust risk management program in 1994 and has provided risk management services to Trust Insured since then.

 

Watch the Recorded Webinar On-Demand

Enter your information to gain access.

  • This field is for validation purposes and should be left unchanged.
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form

Hope

Posted on by erics

Hope is such a simple word. Yet for suicidal people in the depths of despair, hope is a beacon that they crave more than anything – but abjectly fear, because to believe in hope means to risk catastrophic disappointment. What I have come to learn over my decades in suicide prevention is that hope is everything to finding a way out of suicidal hell and into a life worth living with purpose and meaning.

There is a recent study of CAMS that I will be talking and writing about for years to come. For now, I will await publication of the investigation before saying more. But one of the key findings that most warmed my heart was how hope is engendered in suicidal patients engaged in CAMS.

Indeed, we know across clinical trials of CAMS that hopelessness is reliably decreased over the course of care while hope—and even optimism—is generated by the intervention as well. I know hope when I see it, and sparks of hope routinely occur at certain key moments across CAMS sessions. Within the first session of CAMS when the clinician and patient collaboratively complete the initial Suicide Status Form assessment there are often tiny sparks of hope. As the patient warily rates and describes elements of their struggle and the empathic clinician listens, validates, and actually gets what they are describing, there can be a glimmer of hope. When the clinician helps the patient elaborate the struggle and does not judge them, shame them, or ever wag a finger, there can be a flash of hope. When the clinician candidly speaks to the goal of keeping even a relatively highly suicidal person out of the hospital (if at all possible), there can be a spark of hope. So you are not going to try to get rid of me and lock me up?.

When the dyad carefully develops the CAMS Stabilization Plan for the patient and the clinician notes that the patient can learn to cope differently without resorting to suicide, there is often a curious look and sometime a twinkle of hope. Perhaps most dramatically, when the dyad completes the initial CAMS Treatment Plan in which the patient’s own suicidal “drivers” are identified (i.e., issues and problems that compel the patient to entertain suicide), goals and objectives are set, and potential interventions to target and treat those very drivers are noted, there is often an unmistakable flash of hope in the patients eyes. “Can you really treat these problems?” says an incredulous patient. In turn, the clinician replies, “…yes, of course we treat these problems all the time and if we do so successfully with you, perhaps you will come to see that you don’t need to end your life.” This is how CAMS-inspired hope may emerge in a first session.

My Suicide Prevention Lab (SPL) at Catholic University has been dedicated to many suicide prevention-oriented studies over many years. But one of the biggest tasks of the SPL my graduate students and I undertake is the fidelity and adherence work that we routinely do as part of clinical trials of CAMS. Fidelity is a solemn obligation within clinical trial research that requires that research investigators ensure that experimental and control treatments are indeed different from each other.

For example, within a CAMS randomized controlled trial (RCT) that means clinicians in the CAMS arm of the trial are doing the intervention adherently (as it was designed to be used) and clinicians in the control arm of the trial are not doing CAMS and are adherently providing the comparison treatment (e.g., usual treatment or Dialectical Behavior Therapy within our trials).

Here is the point: our job in these RCTs is to watch a lot of digital recordings of clinicians doing CAMS and often watching control sessions to ensure that the control treatment is being done properly. In other words, this fidelity work means we watch hundreds of hours of therapy sessions with suicidal people who are willing to participate in a RCT. It is from this perspective that my trained eye has come to recognize the behavioral, verbal, and emotional indicators of hope.

Hope is sometimes reflected in the almost shy glance that a patient makes towards the clinician—it is a look that says, are you for real? Can I trust you? Do you really mean it when you say you care about me? In later interim sessions of CAMS, hope is seen in a patient who sits up just a little straighter than they did in earlier sessions and who is genuinely interested in the clinician’s comments and input on their life and death struggle. Hope is seen in the flicker of smiles between patient and therapist as the dyad reviews “a good week.” Hope is often seen in an outcome-disposition session that formally draws CAMS to a close, wherein both parties reflect on how far they have come, appreciating and taking stock of gains made, and look forward to the road ahead in the patient’s “post-suicidal life.”

While the quantitative clinical trial results are robust, we know that decreasing hopelessness and increasing hope within CAMS is the lifeblood of a successful course of CAMS-guided care. Hope is simply the remedy to suicidal despair, desolation, despondency. And when you have seen the spark of hope in the eyes of suicidal person, you will never forget it. It is as if an entire inexorable fatal world view has been paused, gradually reconsidered, and even transformed into a world of potential possibilities.

In truth, hope does not happen every time with every patient. But within adherently provided CAMS we know that hope happens more often than not, and when hope happens truly anything is possible.

Such a simple word, hope, but in the suicide prevention and life-worth-living business it speaks volumes.

Meeting the Growing Need for Training in Evidence-Based Suicide Prevention and Treatment

While there are many obstacles to training in effective suicide & evidence-based prevention and treatment, CAMS-care tackles the alarming training deficit with a robust offering of training on how to use the evidence-based and outcome-based CAMS (Collaborative Assessment and Management of Suicidality) system of care.

CAMS-care understands that suicide prevention requires equipping healthcare workers and clinicians with effective training. To fulfill the mission of reducing suicide deaths globally, CAMS training is thoughtfully crafted to be accessible and impactful for individuals and organizations alike, ensuring that the necessary knowledge and skills can be disseminated widely to those committed to suicide prevention efforts.

CAMS-care Suicide Prevention Training Highlights

Easily Accessed

Especially in this age of COVID-19, online delivery systems make remote training accessible while limiting in-person contact. All elements of CAMS training are available online, including role-playing modules and consultations.

Convenient & Flexible for Busy Schedules

Since all CAMS training is on-demand, it can be completed at any time, and there are no deadlines. Clinicians and healthcare workers can complete the materials at their own pace, at any time convenient to them. This level of flexibility helps facilitate training for anyone, regardless of their schedule.

Affordable for Individuals & Companies

Although the CDC reports that suicide is the 10th leading cause of death in the United States and the second leading cause of death in youth, funding for suicide prevention and treatment lags behind other top causes of death, as pointed out in a 2018 article by USAToday. However, CAMS-care’s training is very affordable, and most budgets can easily accommodate the cost – whether they be individual modules or through a company.

Increases Confidence

Working with suicidal patients can be intimidating at first for many healthcare providers, especially when they are unsure of how to best interact with clients who present with suicidal behaviors & tendencies. It’s not always clear how to best help them. CAMS-care’s suicide prevention training recognizes these challenges and provides clinicians with the knowledge and tools to gain confidence in working with even the most challenging cases. Thousands of clinicians and organizations all over the world are using CAMS as their preferred method of training and treatment.“The CAMS model and training tools have very quickly helped us to feel more confident and prepared to manage risky patients. Assessment and treatment in these cases are often confusing, and we have benefitted greatly from the structure of the CAMS approach, which has helped us on a case by case basis to understand the phenomenon of suicide risk and organize our treatment approach. I have yet to find a comparable framework that is as accessible to clinicians and yet so robust.” –Eric Lewandowski, NYU Langone

Evidence-Based and Outcome-Based Treatment Plans

The CAMS Framework® is backed by 30 years of on-going clinical research, with replicated data across various clinical research studies. In fact, the Joint Commission issued a Sentinel Event Alert on February 24, 2016 titled Detecting and Treating Suicidal Ideation in all Settings. In recommendations for Behavioral Health Treatment and Discharge, CAMS was identified as one of four “evidence-based clinical approaches that help to reduce suicidal thoughts and behaviors.”

Mitigates Suicide Malpractice Risk

Often, the reality and proliferation of malpractice lawsuits prevent even the best, well-meaning therapists from treating suicidal patients – and that’s a significant loss for the 12 million suicidal ideators in this country. However, proper documentation using evidence-based, suicide-specific treatment greatly reduces this risk, and the CAMS “Suicide Status Form (SSF)” provides just that. With the SSF, which is a collaborative tool used in every treatment session, CAMS helps clinicians complete exhaustive medical record documentation that ensures competent clinical practice that far exceeds the standard of care and decreases exposure to malpractice liability.

 

New “CAMS Trained™” and “CAMS Certified™” Designations

To further support CAMS-care’s mission to save lives by training clinicians to effectively treat suicidal patients, CAMS-care now offers “CAMS Trained” and “CAMS Certified” designations. These designations offer a clear path to those seeking to help treat & prevent suicidal ideation by creating a network of accessible care for patients.

CAMS Trained

The path to becoming CAMS Trained requires only 10 hours of course work and 4 hours of consultation calls when working with patients. Course work involves completing 4 elements:

    • The CAMS Foundational Video Course
    • Online Role-Play Training Day
    • CAMS Consultation Calls
    • CAMS Book

All training is available online. For an additional fee, up to 16 Continuing Education Credits are available.

Anyone with the CAMS Trained designation has the option of being included in the online CAMS Clinician Locator, which helps those in need find qualified CAMS providers in their area.

Learn more about becoming CAMS Trained here.

CAMS Certified

Building on the foundation received with the CAMS Trained designation, becoming CAMS Certified involves demonstrating your knowledge of and adherence to the CAMS Framework

Learn more about CAMS Certified here.

Death by suicide rates are sadly on the rise, but with effective training in evidence-based suicide prevention systems of care, we can slow this trend, together.

About the Author

Andrew Evans - CAMS-care President and COO

Andrew Evans - CAMS-care President and COO
Andrew Evans is the President and COO of CAMS-care, the exclusive training company for the Collaborative Assessment and Management of Suicidality, created by world renowned suicidologist, <a href="https://cams-care.com/about-us/meet-david-a-jobes/" target="_blank" rel="noopener">Dr. David Jobes</a>. <a href="https://www.usatoday.com/in-depth/news/nation/2020/02/27/suicide-prevention-therapists-rarely-trained-treat-suicidal-people/4616734002/" target="_blank" rel="noopener">Very few clinicians receive any training in suicide prevention</a> so they lack confidence and feel unprepared to work with people who have serious thoughts of suicide. CAMS-care has trained over 30,000 clinicians in CAMS as part of its mission to save lives through effective care.

See More Articles by this Author

About Andrew Evans - CAMS-care President and COO

Andrew Evans - CAMS-care President and COO
Andrew Evans is the President and COO of CAMS-care, the exclusive training company for the Collaborative Assessment and Management of Suicidality, created by world renowned suicidologist, Dr. David Jobes. Very few clinicians receive any training in suicide prevention so they lack confidence and feel unprepared to work with people who have serious thoughts of suicide. CAMS-care has trained over 30,000 clinicians in CAMS as part of its mission to save lives through effective care.

Considering Suicidal Ideation—Again!

Posted on by erics

In recent years I have spoken, published, and blogged about the relative importance of suicidal ideation as a public health concern that does not get the proper health concern of the public. A couple of other reminders came up just last week that again underscores the need to fundamentally shift our focus to appreciating the magnitude of the suicidal ideation population, which is 225 times greater than the population of those that die by suicide.

I was reviewing the most recent 2019 data from SAMHSA about the incidence of suicide-related concerns among American adults that calendar year. Take a close look at Figure 60 from the SAMHSA report—does anything particularly strike you?

Serious Thoughts of Suicide Graph

As I look at this figure my eyes are naturally drawn to the highlighted blue, green, and yellow regions that respectively reflect those who made suicide plans, those who made plans and attempted suicide, those who attempted suicide, and finally those who made no plans and attempted suicide (not sure how that works exactly but such are the data).

But upon some reflection, what jumps off the page to me is that the outer circle depicts 12,000,000 American adults with serious thoughts of suicide which is not highlighted, earning only a modest gray coloring. This SAMHSA report figure thus completely fails to highlight the true objective magnitude of our suicide ideation challenge!

My question is: Why is this population graphically trivialized in this figure? In truth, 12M Americans is a massive population, roughly the size of the state populations of Pennsylvania or Illinois. If we are truly examining the challenge of suicide as a public health issue, we of course care deeply about 48,000+ of Americans who died by suicide in 2018, and the 1.4M attempting suicide in 2019 is extremely concerning as well – but frankly these populations are utterly dwarfed by the massive suicide ideation population. And it logically follows that if we were better at identifying and treating this gigantic population, we may have many fewer attempts and ultimately many fewer completions. Right?

As I recently blogged, I have been honored to be a part of a small team that is working to write an addendum to the 2018 Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe promulgated by the National Alliance for Suicide Prevention. This draft addendum focuses on the apparent inclination of some health care systems to discontinue or suspend screening and assessment of suicidal risk since the Covid-19 pandemic which has driven our health care to online/telehealth modalities. In the forthcoming addendum there is a reassertion that even within telehealth there is a reasonable way to screen and assess for suicide risk (even if this is done asynchronously). In the addendum we have argued that not asking about suicide is no way to go about actually preventing suicides. After all, it is hard to save lives if we do not know that patients are at risk.

Here is the point: in my final review of the carefully written document our language tended to emphasize depression and suicidal behaviors, not even mentioning the importance of suicidal ideation. Even I, who have held these beliefs for some time, completely missed this omission in early drafts!

Mind you, depression and suicide are not synonymous; out of the 132 Americans that die from suicide each day in the U.S., roughly half may be clinically depressed (many others will be psychotic, anxious, substance abusing, personality disordered, etc.). In other words, depression is not even remotely the cause of many of our suicides since millions of Americans are clinically depressed and only a small fraction of them die by suicide.

In my final review of our addendum I made edits to de-emphasize depression and suicidal behaviors in lieu of emphasizing suicidal ideation, particularly as it relates to screening and assessment within a telehealth modality during a worldwide pandemic. I am pleased to note that while depression remains in the document, we have properly underscored the import of suicidal ideation and cited the SAMHSA paper noted above.

This is not going to be the last time that I appeal for us to recalibrate our suicide prevention policy, research, and clinical care focus to stop this peculiar bias to overly focusing on suicidal behaviors while dangerously disregarding suicidal ideation. My journal papers should not be rejected because CAMS “only” reduced suicidal ideation. Indeed, I would note within the clinical treatment research that other excellent suicide-focused interventions (e.g., DBT, CT-SP, and BCBT) do not reliably reduce suicidal ideation like CAMS does. However, these interventions more reliably reduce suicide attempts (while CAMS has only promising behavioral data thus far). The clinical trial data to date are exactly why I have strongly argued for a “one size does not fit all” approach to care for suicidal risk.

So, I am going to keep on banging the suicide ideation drum, appealing to those in our field to more completely consider the import and magnitude of the suicidal ideation population. In truth, if we truly aim to reduce completed suicides, our research, practices, and policies must better target and treat the underlying iceberg of suicidal ideation so as to reduce the tip above the water of suicide attempts and ultimately deaths by suicide.

Vermont’s Zero Suicide Initiative

Vermont’s suicide rate has increased by 73.1% since 1999, which marks the 4th largest increase of any state over this time period. Prior to 2008 there was no structured approach in Vermont for reducing suicide deaths in the State.

In 2008, a small group of suicide loss survivors, non-profit and state partners applied for and received a three-year Garrett Lee Smith (GLS) grant from the Substance Abuse and Mental Health Service Administration (“SAMSHA”) to promote suicide prevention among youth. A second GLS Grant was received in 2011, bolstering the emergence of a strong statewide cross-sector Coalition managed by the Center for Health and Learning. The Vermont Suicide Prevention Coalition committed themselves to a lifespan approach and developed the Vermont Suicide Prevention Platform-Working to Prevent Suicide Across the Lifespan. The Platform was based on the National Strategy for Suicide Prevention and has served as a guidance document for the state.

An infrastructure survey indicated the need for an entity to provide leadership and direction for suicide prevention, and the Vermont Suicide Prevention Center (VTSPC) was formed as a public-private partnership to provide sustainability beyond the federal grant, and to ensure input from PWLE and a multi-sector approach. The Center has sustained its work for the past five years on a small state allocation, coupled with projects funded by foundations, and private donor support.

In 2011, Dr. Jay Batra, the medical director of the state hospital system, and Dr. JoEllen Tarallo, the Executive Director for the Center for Health and Learning, and Director of the VTSP Center, attended the annual American Association of Suicidology conference where they listened to Dr. Michael Hogan’s presentation on the Zero Suicide Initiative: a system-wide organizational commitment to safer suicide care in health and behavioral health care systems. Zero Suicide is an approach that meets Goal #7 of the Vermont Platform: Promote suicide prevention, screening, intervention, and treatment as core components of health care services with effective clinical and professional practices.

The Zero Suicide Initiative includes a toolkit introducing the following seven elements:

1. LEAD System-wide culture change committed to reducing suicides
2. TRAIN A competent, confident and caring workforce
3. IDENTIFY Individuals with suicide risk via a comprehensive screening and assessment
4. ENGAGE All individuals at-risk of suicide using a suicide care management plan
5. TREAT Suicidal thoughts and behaviors using evidence-based treatments
6. TRANSITION Individuals through care with warm hand-offs and supportive contacts
7. IMPROVE Policies and procedures through continuous quality improvement

 

Dr. Hogan’s presentation inspired Dr. Batra and Dr. Tarallo to create Vermont’s own Zero Suicide Initiative.

The Coalition has maintained a strong presence annually at the statehouse, and a one-time allocation of $50,000 has grown to an annual grant of $220,000 from the State to support a population-wide health approach to suicide prevention focused on reducing the number of Vermonters who die by suicide each year. The purpose(s) of the Program is to:

  1. Support public education and information to improve awareness and access to suicide prevention support and services;
  2. Develop and support policy, stakeholder engagement, and a suicide prevention infrastructure to improve suicide prevention planning and implementation;
  3. Advance best and evidence-based practices for suicide prevention through workforce development;
  4. Promote social and emotional wellness to prevent suicides in Vermont.

This is a lot of work to do with just $220,000 a year, and yet the Vermont Suicide Prevention Center has continued its work to comprehensively build a Zero Suicide system of care that addresses all the elements of the Zero Suicide Toolkit.

As this graphic illustrates, in Vermont’s continuum of care the staff use a number of tools to identify, engage, treat, and transition clients.

CAMS’ Role

Within the Vermont pathway to suicide safer care, Umatter, ASIST, and/or QPR are used to train the community and workforce as Gatekeepers, to recognize warning signs, know what to say and do, and how to get help. A standard screening and assessment form (the C-SSRS) is used to identify suicidal ideation, leading to the client being seen by a clinician trained to treat that person using the Collaborative Assessment and Management of Suicidality (CAMS).

The evidence base for CAMS made it an obvious choice to adopt as a treatment in Vermont’s system of care. Dr. Tarallo explained that “the state Zero Suicide Steering Group, which was composed of a variety of clinicians and stakeholders, selected CAMS because of the research base, its strong track record as both an assessment and treatment tool, and because it promotes a collaborative approach with the patient using a set of structured tools. The group was strongly influenced by the data which shows that a structured tool trumps individual professional discretion in a research-based trial every time. The body of evidence for CAMS and the Suicide Status Form is significant and robust.”

Measuring Success

With a background in systems change management, Dr. Tarallo and her team have been using the Concerns Based Adoption Model (CBAM) to guide the implementation of the Vermont Suicide Prevention model. Successfully implementing a new program involves more than providing staff with materials, resources, and training. An often-overlooked factor is the human element—the people actually doing the work. Each person responds to a new program with unique attitudes and beliefs, and each person will use a new program differently. VTSPC has a long term relationship partnering with an evaluator from the Larner College of Medicine at the University of Vermont to evaluate program implementation and collect client level outcome data.

VTSPC has worked with more than 250 clinicians across seven mental health agencies and while they are using the same tools there are differences in approaches and hence variations in outcomes. VTSPC is currently collecting two of the 12 measures for Zero Suicide: screening and safety planning. For screening, they are looking at how many screenings are being performed and in which locations. Not all clinicians are using qualified safety planning tools so the goal is to review these documents and produce guidelines for consistency and quality standards.

A key part of measuring the success of the program is to have documentation and results available in the various Electronic Medical Records. CAMS-care is working with several agencies in Vermont to allow clinicians and mental health centers to use electronic versions of the Suicide Status Form, which will facilitate better tracking of people treated for suicidal ideation and the outcomes. Under short-term COVID relief emergency funding, the VTSPC is working with the VT Department of Mental Health and VT Department of Health Care Access to engage primary care practices in the Vermont “Blueprint” in the pathway of care.

Future Plans

VTSPC has developed a Zero Suicide program that is a model for many other organizations and States. Most impressively, they have achieved this with limited State funding.

With additional funding, the VTSPC would deploy such resources to:

  • Raise awareness of the Zero Suicide program;
  • Reduce the stigma of seeking help for those in need;
  • Further invest in people and facilities to identify and treat suicidal people;
  • Continue to train clinicians in evidence-based protocols and tools;
  • Measure results to show that the Zero Suicide initiative is benefiting Vermonters.

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.