Who You Treat: Veterans & Military Personnel

Supporting Clients Between Sessions: Peer Support and New Data from NowMattersNow

When clients are struggling most, support often needs to extend beyond the therapy hour. This webinar introduces Now Matters Now’s (NMN) three free programs, with a focused look at NMN Peer Support Meetings and new engagement and outcomes data, highlighting how peer support can complement CAMS-informed care between sessions.

Ursula Whiteside, PhD

About Ursula Whiteside Ph.D.

Dr. Ursula Whiteside is a licensed psychologist, certified DBT clinician, and founder/CEO of NowMattersNow.org. She trained for over a decade directly with Dr. Marsha Linehan, the creator of Dialectical Behavior Therapy. Today, NowMattersNow.org hosts the world’s largest lived-experience DBT skills library, offers free weekly DBT Peer Support Meetings, and provides a brief intervention for overwhelming suicidal urges.

Dr. Whiteside serves as Clinical Faculty at the University of Washington and as national faculty for the Zero Suicide initiative. She is co-founder of United Suicide Survivors International and advises on AI chatbot development, centering the lived experience, preferences, and safety of suicidal users. Dr. Whiteside is open about her experiences with intense emotions and suicidal thoughts.

 

David A. Jobes, PhD

About David A. Jobes, Ph.D. ABPP

David A. Jobes, Ph.D., ABPP, is a Professor of Psychology, Director of the Suicide Prevention Laboratory, and Associate Director of Clinical Training at The Catholic University of America. Dr. Jobes is also an Adjunct Professor of Psychiatry, School of Medicine, at Uniformed Services University. He is the author of seven books and hundreds of articles and book chapters. He is the creator of the Collaborative Assessment and Management of Suicidality (CAMS) and one of the founders of CAMS-care, LLC (a professional training and consultation company). Dr Jobes is the recipient of many awards such as the 2022 Alfred M. Wellner Award for Lifetime Achievement (for research excellence) from the National Register of Health Service Psychologists and the 2025 “Erwin Ringel Service Award” for contributions to suicide prevention from the International Association of Suicide Prevention (IASP). He is a Fellow of the American Psychological Association and is board certified in clinical psychology (American Board of Professional Psychology). Dr. Jobes maintains a private clinical and consulting practice in Washington DC and in Maryland.

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Cultural Perspectives on Suicide: How Different Societies Approach Prevention

Posted on by STOLBER Digital

Cultural Perspectives on Suicide

When it comes to suicide prevention, cultural awareness is extremely important. Every culture has their own views of suicide, stemming from their histories and belief systems. Therefore, not everyone addresses suicide prevention efforts in the same ways. Here is a look at how various cultures from around the world have historically viewed suicide and how some of them approach prevention.

Eastern Views and Approaches to Suicide


Historically, countries in Eastern cultures have had a more positive view of suicide than those in Western cultures. For example, in some Asian countries, suicide used to be viewed as a noble or honorable act. China is one example of an Eastern country that has shifted its view on suicide over time. Suicide was seen as honorable when it was done for social or political causes. It was even viewed highly when Confucianism was the main philosophy throughout the country. China saw their worst rates of suicide in the 1990s. [1] However, the rates dramatically declined in the decades to follow. There may be several factors at play. One possibility is fast economic growth. Another factor could be surveillance-based monitoring of students on college campuses. [2] China has also been working to reduce air pollution, as some studies have shown a connection between air pollution and suicide rates. [3] 

Japan is another Eastern country that has shifted its perceptions of suicide. Its general attitude toward suicide has been described as “tolerant.” [4] Similar to China, Japanese cultures have historically viewed suicide as honorable or “morally responsible” when it’s performed as a ritual. Also similar to China, Japan experienced a spike in suicide rates in the 1990s when they experienced an economic crisis. However, unlike China, Japan’s rates have not recovered to the extent that China has seen. Japan has, though, been working toward getting its rates down. In 2006, the government initiated a national suicide prevention strategy that helped reduce suicide rates by 35% by the year 2022. [5] This strategy along with other prevention efforts have helped the topic of suicide to be less of a taboo in Japanese culture. Instead, it is starting to be seen as a legitimate health concern.

 

Western Views and Approaches to Suicide


Western cultures have historically had a much more negative view of suicide compared to Eastern cultures. In these cultures, suicide is often seen as shameful and cowardly. It is also considered illegal in some places. In fact, the term “commit suicide” comes from when suicide was a crime and those who survived suicide could be imprisoned. [6] Much of the stigma surrounding suicide stemmed from Judeo-Christian beliefs and teachings that have been prominent in Western cultures. These teachings considered suicide immoral and punishable. While these religious overtones may no longer be as prominent, the stigma has lingered. This has caused many to struggle in silence, feeling ashamed and hesitant to get help. 

Historically, Western cultures have had a more clinical approach to suicide. They focus on identifying and treating mental illness that may be associated with it. This differs from other cultures. In more recent years, however, the topic of mental health has been more openly talked about. Wider prevention strategies started being put into place. For example, the 2024 National Strategy for Suicide Prevention was developed in the U.S. as a 10-year, whole-of-society approach to preventing suicide. Rather than only focusing on the clinical aspect, this strategy addressed health equity and community-based prevention methods.

 

African Views and Approaches to Suicide


Cultures in African countries also have their own unique perspectives when it comes to how they view and handle the topic of suicide. The cultures and belief systems throughout Africa vary greatly depending on the region. Many cultures view suicide as a taboo topic. This is often due to fear and unknowns surrounding mental health and illness in these cultures. Belief systems play into this, as well, with some cultures viewing suicide as the result of evil spirits or inherited curses. In some countries, such as Ghana and Uganda, suicide is punishable by law and can have severe consequences for the person’s family and community. [7]

Historically, there was an assumption that countries in Africa had low suicide rates. However, this was likely due to a lack of reporting and studies on suicide deaths in African countries. It has since been found that suicide is a public health concern. [8] Due to the vast diversity of culture and lack of data, suicide prevention strategies for African regions have been difficult to implement and research. However, many African cultures highly value community-based efforts. Traditional healers are important in many countries. One example is in South Africa. They have played a crucial role in helping people at risk of suicide. [9] 

 

Indigenous Views and Approaches to Suicide 

 

Indigenous cultures have struggled with significantly higher rates of suicide than non-Indigenous cultures, specifically in North America. [10] There are many factors that play a role in this, including generational trauma, loss of cultural identity, and issues related to poverty. Many Indigenous communities see suicide as a symptom of their broader collective trauma. However, many of these cultures have had stigmatized views of suicide for generations, making it difficult to approach the subject and receive help.

Because community is at the heart of Indigenous culture, Indigenous-specific approaches to suicide prevention often prioritize community-based and culturally grounded practices. This might include performing ceremonies, storytelling, connecting with the land, and finding ways to celebrate and honor their culture. [11] Elders also play a central role in supporting youth and restoring these generational and cultural ties. Rather than focusing on the individual, Indigenous strategies aim to heal the collective spirit and restore harmony within the entire community.

Suicide occurs in all countries and cultures. However, there are different ways to approach it. These methods should specifically resonate with the people who are affected. Learning about cultural differences helps us understand and stay aware that some forms of prevention may be more appropriate than others. The overarching theme, though, appears to be the need for community and meaning. Even though this may be found and approached in different ways, everyone needs to know that they matter to others and that their life has significance. 

Sources:

[1] https://www.sciencedirect.com/science/article/pii/S2352827323000071 

[2] https://www.healthdisgroup.us/articles/APM-5-125.php 

[3] https://news.ucsb.edu/2024/021373/clearing-air-reduces-suicide-rates 

[4] https://www.suicidecleanup.com/culture-and-suicidal-behavior/  

[5] https://www.who.int/news-room/feature-stories/detail/suicide-prevention-in-japan–a-public-health-priority 

[6] https://learning.nspcc.org.uk/news/why-language-matters/rethinking-language-suicide

[7] https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2021.549404/full  

[8] https://www.sciencedirect.com/science/article/abs/pii/S1876201823004355  

[9] https://www.madinamerica.com/2018/05/traditional-south-african-healers-use-social-bonds-connection-suicide-prevention/

[10] https://pmc.ncbi.nlm.nih.gov/articles/PMC3483901/ 

[11] https://pmc.ncbi.nlm.nih.gov/articles/PMC9588522/ 

2024 CAMS Update and Introducing CAMS Brief Intervention

2024 CAMS Update and Introducing CAMS Brief Intervention

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

David A. Jobes, PhD

About David A. Jobes Ph.D. ABPP

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

Dr Raymond Tucker Headshot

About Dr. Raymond P. Tucker

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

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Zero Suicide – Outcomes and Opportunities

Zero Suicide - Outcomes and Opportunities

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

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

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

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

Julie Goldstein Grumet, PhD

Julie Goldstein Grumet, PhD

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

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10 Tips for Using CAMS with Adherence

Posted on by erics

For a proven intervention to be effective in the field, clinicians must use the intervention with adherence, meaning it is used as designed, based on extensive support from clinical trial research. Clinical adherence challenges are particularly prominent when conducting a randomized controlled trial (RCT)—which is the gold standard methodology for proving an intervention is effective.

The Importance of Adherence in Randomized Controlled Trials

Within RCTs, researchers must ensure that an experimental treatment is reliably provided with adherence and that there is fidelity between experimental treatment arms (i.e., that in fact the targeted treatment and control treatment were administered as intended). There are currently six published and four active CAMS RCTs — three funded by the National Institute of Mental Health and a fourth funded by Veterans Affairs.

Across these RCTs, members of The Catholic University Suicide Prevention Laboratory (SPL) that I direct take the lead in training CAMS to RCT study providers. In turn, we are also responsible for watching digital recordings (on secure platforms) of clinicians endeavoring to provide CAMS with adherence with patients who are suicidal.

The Role of Adherence Feedback in RCTs

To do this with scientific rigor, we use two expert SPL coders rating each session using the CAMS Rating Scale (CRS) with high inter-rater reliability. In addition, SPL graduate students also watch comparison control sessions (e.g., clinicians providing “treatment as usual”—TAU) to ensure that these clinicians are doing the comparison control treatment—and not doing CAMS—confirming experimental fidelity.

To this end, over the fall semester of 2022, the SPL has been working hard to support the three NIMH-funded CAMS RCTs which means beyond the initial CAMS trainings that I lead, we all watch a lot of digital recordings of clinicians working diligently to provide CAMS with adherence.

This means SPL members watch dozens of sessions each week. I personally watched 15 recordings over the past few weeks. It’s a busy time for members of the SPL supporting providers across three RCTs to fully meet our criteria for adherence to CAMS. Once study providers are determined to be adherent, our workload decreases significantly as we do random spot checks to confirm that clinicians do not fall out of adherence (which can require training remediation work with providers if this occurs).

10 Tips for Becoming Adherent to CAMS

With this immersion of training and adherence it is inevitable that we encounter common challenges when providers are learning to use CAMS. With a bit of constructive CRS feedback and consultation coaching with our teams of providers, many of these issues quickly become a one-trial learning experience. Moreover, other providers on our consultation calls benefit from hearing about our constructive adherence feedback with their colleagues.

Within a matter of weeks, we usually get most of our clinical providers to meet adherence criteria to effectively provide CAMS. I would note that learning to use CAMS is not as challenging as learning other proven approaches in mental health. Dialectical Behavior Therapy, for example requires labor intensive training that may take months to achieve. But while CAMS is typically learned in fairly short order, there are still common mistakes when first using CAMS that can delay achieving adherence to the framework.

This blog is intended to help other beginning CAMS providers avoid some mistakes that we see among clinicians learning this model. Based on this adherence work let us thus consider 10 of the best tips for becoming adherent to CAMS.

Watch the Video Series 

1. Dive Right into CAMS

We often see a hesitancy on the provider’s part to dive right into using the Suicide Status Form (SSF) at the start of each session, especially with clinicians unfamiliar with CAMS. From the first session through interim care, there is too often unnecessary small talk or avoidance of starting into the SSF assessment using up valuable session time (particularly in the labor-intensive first meeting). The feedback we get is that clinicians feel that they have to form some sort of relationship with the patient before they can broach the sensitive topic of suicide. However, our extensive clinical trial research and one meta-analysis show that patients welcome SSF engagement getting to the heart of their struggle with suicide.

Indeed, when clinicians experience the patient feeling validated and understood by the SSF assessment, the temptation to avoid getting into the SSF assessment at the start of each session of CAMS quickly dissipates. Bottom line, suicide is serious business and there is no need for chit-chat at the start of each session of CAMS—let’s get down to business!

2. Interact During Suicide Status Form Core Assessment

The SSF Core Assessment is used at the start of every session of CAMS. Too often we see the clinician have the patient complete their SSF ratings of pain, stress, agitation, hopelessness, self-hate, and overall risk of suicide in silence. Using this approach, providers then typically review patient’s ratings and have some observations or some comments after the ratings are made.

In contrast, the completion of the SSF Core Assessment ratings offers a superb opportunity to discuss the patient’s ratings as they complete each SSF rating scale. This approach creates more of an ongoing dialogue about the ups and downs of suicidality and underscores the importance of candid and collaborative discussion of what the patient is experiencing as they complete these ratings.

3. First Session—Focus on Reasons for Dying (Instead of Reasons for Living)

Ever since I created the Reasons for Living (RFL) versus the Reasons for Dying (RFD) assessment as a major focus in the first session of CAMS, I have observed that clinicians often enthusiastically focus on the patient’s RFL responses. Understandably clinicians focus on RFLs as potential protective factors that might mitigate the patient’s suicide risk. However, based on two studies that we did with a large clinical trial sample in Switzerland, I have now come to see RFLs as a clinician assessment because patients we have studied are actually more focused on their RFDs in their first session!

When I train the model I therefore discourage RFL “cheerleading” because for some patients emphasizing their RFLs can invalidate their current struggle. At its worst, pushing RFLs can even be shaming! It is not uncommon to see inexperienced CAMS clinicians pointing out possible RFLs that the patient has not spontaneously generated — “What about your kids?” or “Isn’t your wonderful wife a reason to live?” Given the clinical trial research findings, we do not want clinicians pointing out RFLs that the patient has not listed.

For example, perhaps a patient sincerely believes they are a burden to their kids or their spouse and that their death may actually be a “gift” to these people. Denying this perspective prematurely can be dismissive of something that the patient may feel deeply. However, within CAMS we absolutely do emphasize RFLs, but we wait to do it later in the course of care when potential clinical progress has been made and the patient is more open to such considerations. Remember, the capstone of successful CAMS-guided care is a focus on the pursuit of a life that the patient actually wants to live. But to push a RFL agenda prematurely risks overriding the patient’s experience and may invalidate what they are going through at the start of care.

4. First Session—Move on Through Section B

Within the first session of CAMS, providers often get bogged down in Section B (which should take only 10 minutes) at the expense of completing the CAMS Stabilization Plan (CSP) and the CAMS Treatment® Plan. We advise in the RCTs that if a first session provider is falling behind, Section B does not need to be fully completed (as it can be completed later). That said, within Section B, it helps to get through the patient’s suicide attempt history, but then move on to the CAMS Treatment Plan focusing on the CSP and the two problem drivers in the remaining time.

5. First Session—CAMS Treatment Planning Always Begins with the CAMS Stabilization Plan

A huge error that even experienced CAMS providers make in the first session, is addressing Problems 2 and 3 before completing the CAMS Stabilization Plan! For adherence to the proven model, the CSP is always addressed first, then Problems 2 and 3 are completed as the final steps at the end of the first session of CAMS.

The reason that the CSP is the first step in the CAMS Treatment Plan is that establishing a sound CSP is the foundation for the entire treatment plan. An ability to satisfactorily complete the CSP may be an indication of imminent danger that might warrant an inpatient admission. However, if we can establish a solid CSP then the goal of CAMS to keep someone out of the hospital can be realized as we then shift the focus to problems/drivers that are usually quite treatable.

6. Have the Patient Identify Their Own Drivers for Suicide

Beyond the initial establishment of the CSP, all CAMS Treatment planning should center on the patient’s identification of their problem/drivers for suicide. In other words, the clinician should not point out the patient’s problem/drivers for them. In turn, the clinician should help the patient identify treatment goals and objectives before taking the lead identifying the full spectrum of interventions to address each respective problem/driver.

Ideally, we like to have more than one intervention for any one problem/driver of suicide. The more interventions we have to offer, the more hope we instill in the patient. Bottom line, the message to the patient is that there are many potential ways for effectively addressing the issues that compel the patient to consider suicide as a solution for their struggles.

7. Interim Sessions—CAMS Treatment Focuses on Crafting the Stabilization Plan and the Patient’s Suicidal Drivers

Across CAMS-guided interim care, all sessions begin promptly with Section A, the SSF Core Assessment. There should then be a check-in about the previous week in terms of the presence of suicidal thoughts, feelings, and behaviors. The clinician should always ask about the CSP sometime during the course of each interim session (often at the start but it can be at the end as well). The focus of all CAMS interim care centers on patient’s problems/drivers and possible updates or revisions to the CSP.

8. Interim Sessions—Treatment Plan Updating

Across CAMS-guided interim care, every session ends with updating the CAMS Treatment Plan. The treatment plan update should be done from scratch and potentially change in each interim session depending on what is happening in the course of care. But too often inexperienced clinicians complete Section A and Section B at the start of the session.

Section A should always be completed at the start of each interim session and Section B at the end of each interim session of CAMS. Moreover, we know from our clinical trial research that CAMS Treatment Plans that change across clinical care lead to better outcomes (in contrast to CAMS Treatment Plans that basically do not change from session to session).

9. You Can Delay Resolving CAMS if Needed

A patient may continue to be engaged in CAMS even when CAMS resolution criteria are technically met. To clarify, just because criteria are met, does not mean that you must necessarily move to the outcome-disposition session. Sometimes deferring the final session can help reassure both members of the clinical dyad that the patient’s apparent recovery is holding up and feels well-established.

10. Emphasize the Goal of Managing Suicidal Thoughts and Feelings to Achieve Behavioral Stability

As a clinical intervention, CAMS can be resolved even when some suicidal thoughts are present. In other words, the treatment difference that CAMS often enables a patient to better and more reliably manage suicidal thoughts and feelings while achieving behavioral stability.

From clinical trial research, we know that CAMS reliably increases hope while reducing hopelessness and overall symptom distress (i.e., general misery and despair). We thus know that CAMS significantly reduces suicide-related suffering and in so doing it can open the door to hope and the pursuit of life that the patient wants to live.
How to Use CAMS in a Clinical Setting

Working with patients who are suicidal is invariably challenging and can be daunting. Frankly, far too many clinicians endeavor to simply avoid such patients. Given this, we in the CatholicU SPL are humbled by and grateful to the clinicians across clinical trials who aspire to use CAMS with adherence.

Imagine having your clinical works viewed and rated with patients that many providers seek to avoid. It is not easy. It requires being open to constructive feedback and inevitable tweaks and suggestions to help one master CAMS. As clinicians in our trials courageously work to learn the intervention, members of the SPL do everything we can to be positive, supportive, validating, and reassuring as we give our constructive CRS feedback. In truth, we deeply admire these providers and clinical trials of CAMS could not be conducted without them. Consequently, the adherence work that we do inspires constructive tips like the ones described in this blog to help other providers achieve adherence to the framework.

The adherence work we do is challenging but worth it. Seeing clinicians quickly master the intervention is incredibly rewarding. When we provide thoughtful guidance on common mistake and provide instructive tips, we will have done our part in helping providers deliver a potentially life-saving course of care that has been proven to decrease suicidal suffering and overall misery. In turn, each RCT we publish increases the evidence base which we hope will may inspire more providers to learn and master this proven suicide-focused clinical intervention.

Learn more about how you can get started with CAMS Training and Certification to help identify suicidal drivers in patients in as little as six sessions.

10 Tips for Clinical Management of Suicide Risk

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

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

Marjan G. Holloway, Ph.D.

About Marjan G. Holloway, Ph.D.

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

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The Stepped Care Model in Clinical Suicide Prevention

Posted on by erics

According to the CDC, 12.2 million Americans seriously thought about suicide in 2020. 1.2 million actually made suicide attempts. With nearly 46,000 deaths per year, suicide remains a leading cause of death in the United States with rates of suicide steadily increasing over the past decade. Yet despite this health care emergency, mental health systems of care are largely underprepared to work effectively with suicidal individuals.

In response to these concerns, a recent policy initiative called “Zero Suicide” has advocated a systems-level response to the suicidal risk within health care and this policy initiative. And it’s working.

A “stepped care” approach has been developed and adapted to work within the Zero Suicide curriculum as a model for systems-level care that is suicide-specific, evidence-based, least-restrictive, and cost-effective. The Collaborative Assessment and Management of Suicidality (CAMS) is an example of one suicide-specific evidence-based clinical intervention that can be adapted and used across the full range of stepped care service settings.

This article describes several applications and uses of CAMS at all service levels and highlights CAMS-related innovations in the stepped care model. Psychological services are uniquely poised to make a major difference in clinical suicide prevention through a systems-level approach using evidence-based care such as CAMS. Here’s how stepped care can improve the effectiveness and efficiency of suicide care.

What is a Stepped Care Approach?

Stepped Care is a system of delivering and monitoring treatment so that the most effective and efficient treatment is delivered to patients first. Patients only “step up” to intensive/specialist services when it’s clinically required.

For example, a stepped care model for suicide care usually starts with suicide or crisis hotline support and follow-ups, like the 988 Suicide Helpline. This is followed by more involved and thus more costly and less easily scalable interventions like: additional follow-ups, emergency care, hospitalization, and finally specialist inpatient psychiatric care or hospitalization.

stepped care model

The goal of stepped care is to use evidence-based assessments, treatment plans, and patient tracking to allow the right people to deliver the right treatment in the right place at the right time to meet each patient’s needs.

Applications and Use of CAMS Across the Stepped Care Model

Suicide prevention and treatment is an immensely complicated and ever evolving field. However, thanks to evidence-based assessment and treatment frameworks, like The Collaborative Assessment and Management of Suicidality (CAMS) and tools like the Suicide Status Form (SSF) which is becoming a part of electronic health records across the country, clinicians can be more equipped to identify, treat, and ultimately prevent suicide.

CAMS has more than 30 years of evidence, five published randomized control trials, and two meta analyses one of which shows that CAMS is a “Well Supported” treatment by CDC criteria and is even proven to “reduce hopelessness and increase hope” in as few as six sessions. In fact CAMS is one of four evidence-based treatments that are referenced by the Joint Commission, Surgeon General and the CDC.

Click here to learn more about how we train physicians to use CAMS to treat and prevent suicide.

Crisis Hotline Support

Staffed by well-trained and compassionate professionals, suicide crisis lines are incredibly important tools in suicide care and prevention. They have the unique ability to provide vital crisis support to a range of suicidal individuals from all walks of life. But more importantly, crisis lines can effectively help suicidal individuals who may not be able to afford or even need costly clinical interventions.

CAMS can be a useful resource for call centers, since crisis center work typically focuses on assessing the immediate risk of suicide or suicidal thoughts through collaborative dialogue. The Suicide Status Form (SSF) is also a well-suited therapeutic assessment tool to efficiently stratify the level of risk during a crisis call, thanks to its easy to learn, structured, yet non-directive framework.

The SSF can also be used to track the ongoing risk of repeat callers, providing continuity of care when multiple crisis workers speak with the same caller over a period of time across shifts. Recent use of crisis text and chat lines present additional opportunities for using the SSF as a framework for collaborative suicide-specific engagement.

Brief Intervention

Emergency departments are often responsible for identifying, performing risk assessments, and referring suicidal individuals to specialist care, often in a high-volume, high stress environment. That’s a lot to ask from ED practitioners. That’s why we developed CAMS Brief Intervention (CAMS-BI™) to help meet this demand.

CAMS-BI is a single first session of CAMS using the SSF to learn about the patient’s suicide risk and the drivers of their suicidality, which leads to the development of a CAMS Stabilization Plan. CAMS-BI can be linked to non-demand caring follow-up contact in any way that’s agreeable to the patient including phone calls, text messages, e-mail, letters, etc. Emergency departments can also give out a Coping Care Package that includes various resources for patients to use after release.

Outpatient Settings

It’s essential for clinicians to attend to, assess, and treat suicidal risk in any mental health service setting. But the Suicide Status Form was originally developed for outpatient care, which means that CAMS is particularly well-suited for general outpatient mental health care services.

CAMS can help mitigate concerns regarding suicidal patients “falling through the cracks” by providing valuable structure and tracking support for both patients and clinicians. CAMS has even been adapted for use in several outpatient settings, including university counseling centers, community mental health centers, employee assistance programs, private practices, military, and Veterans Affairs behavioral health settings, and even successfully adapted to accommodate cultural considerations for use in countries around the world (Lithuania, China, Western Europe, and Australia).

Here is how CAMS is improving stepped suicide care in various clinical settings.

University Counseling Centers

CAMS has been successfully used in university counseling centers for years, and has proven to be especially adaptable to the unique culture of college life. One of the biggest strengths of CAMS on college campuses is how it integrates available resources in the university setting into the framework.

Empowering resident advisors, student-run organization, campus ministry, and health care services with the resources they need to help intervene with certain suicidal drivers and participate in the therapeutic process increases campus-wide awareness of suicidal risks while making the assessment and treatment stages of the process more efficient and effective for everyone involved.

Community Mental Health Centers

Clinicians working in Community Mental Health Centers often face unique challenges not limited to large case-loads, a chronic lack of resources, and an array of complex cases. CAMS can offer solutions to many of these challenges.

In a large-scale 5-year roll out of CAMS across the state of Oklahoma, CAMS was effectively adapted for CMHC patients with psychotic disorders and developmental delays. CAMS also increased hope and reduced suicidal ideation and overall symptom distress for outpatient CMHC patients, 40% of whom were homeless.

Independent Practice

Many clinicians in independent practice may feel particularly vulnerable and isolated when working with suicidal patients as they may not have access to various resources or a team of colleagues to help provide services and professional support. CAMS can provide clinicians with a clear procedural outline for assessing, treating, and tracking a suicidal patients’ progress, with tools like the SSF to increase their confidence and effectiveness at identifying and treating suicidal thoughts and ideations.

Military

Suicide remains a significant problem in the U.S. military, with many military Behavioral Health Clinics lacking a system for tracking ongoing suicidal ideation. As a consequence of this care gap many service members experience psychiatric hospitalization, which is not only inefficient, but often ineffective as suicide-specific treatment is typically limited.

Given the scope and scale of the problem, CAMS’ evidence-based, adaptable framework for assessing, tracking, and treating suicidal risk can provide an effective and scalable solution within military treatment facilities. It also addresses one of the biggest challenges for suicide care in the military — service members may not stay in one location long enough to complete a lengthy treatment protocol.

To help tackle this, CAMS aims to efficiently resolve suicidality in as few as six to eight sessions, and there’s a growing interest in the use of CAMS for military populations through telehealth.

Like standard CAMS, telehealth allows clinicians and behavioral health specialists to work together by jointly following the SSF as their clinical road map. Given the large number of service members who may not be able to access a treatment facility due to deployment, residing in remote areas, or physical disabilities, telehealth may provide a viable alternative to standard care. And many younger military members may also prefer a telehealth treatment option.

Veterans Affairs Outpatient Settings

Over many years CAMS has been extensively trained to providers across VA mental health treatment settings including VA medical centers and Community-Based Outpatient Clinics (CBOCs).

VA clinicians have a keen interest in the model and suicidal veterans anecdotally find the model helpful, but further clinical trial research is needed which is now being pursued by our research team.

Emergency Respite Care

As mentioned earlier, over the past several years, the state of Oklahoma has embraced the Zero Suicide policy model and has sought to systematically train CAMS to providers in their public mental health system. As part of their process improvement initiative, hundreds of outpatient providers and clinicians who work in brief intensive respite clinics have been trained to use CAMS in places where suicidal patients are stabilized over a 48-hr period and then discharged.

In the optimal care transition model, CAMS is initiated within crisis respite care to help stabilize the patient who is then discharged to a CAMS-trained provider who can continue the CAMS-guided care initiated in respite in an uninterrupted manner on an outpatient basis.

Partial Hospitalization

There has been some interest in using CAMS within partial hospitalization service settings. For example, there was some early clinical use of CAMS within a group format for severely mentally ill patients in a day treatment program within a VA Medical Center.

Partial programs offer intensive treatment in a more cost-effective and least-restrictive form of care. So it seems inevitable that CAMS will increasingly be used in such settings in the years ahead as a viable alternative to more expensive inpatient psychiatric care.

Inpatient Psychiatric Hospitalization

Within the current system of mental health care, individuals who are at imminent risk for suicide are often referred for inpatient care. And while the inpatient psychiatric setting may provide a safe and supportive environment for specific acute care services and stabilization, most of the interventions provided to suicidal patients are neither suicide-specific nor evidence-based.

In a report from the Suicide Prevention Resource Center (SPRC) and SAMHSA DJ Knesper noted:

“. . . the research base for inpatient hospitalization for suicide risk is surprisingly weak. This review could not identify a single randomized controlled trial about the effectiveness of hospitalization in reducing suicidal acts after discharge”.

Thankfully, this is changing as adaptations of the SSF and CAMS are being used to effectively assess and treat suicidal risk within inpatient settings. Most notably, the Mayo Clinic has used the SSF assessment to inform inpatient treatment and disposition discharge planning, and has further integrated the SSF into their routine assessment used with all patients at admission.

In terms of treatment, a Swiss team created an inpatient version of CAMS that was associated with dramatic decreases in overall symptom distress and suicidal risk in a sample of 45 suicidal inpatients over the course of 10 days of inpatient care.

Our team is currently exploring the use of an intensive inpatient version of CAMS, called CAMS Intensive Inpatient Care (CAMSIIC) which has been used in several inpatient treatment settings within the U.S. over a 3- to 6-day hospital stay. CAMS Brief Intervention involves conducting Session 1 of CAMS during a brief inpatient stay, necessitates the development of a stabilization plan, discussions of access to lethal means, and preliminary identification of issues in need of treatment (i.e., suicidal drivers) all of which should be quite relevant to the disposition of the patient upon discharge.

An adapted inpatient version of CAMS has also been used successfully at the Menninger Clinic in Houston, Texas. Referred to as CAMS-M, this adaptation offers CAMS twice per week with highly suicidal inpatients over a 50- to 60-day stay with clinicians focusing on intensively treating suicidal drivers while the nursing staff focuses on stabilization planning. The entire team then focuses on meaningful suicide-specific disposition and discharge planning.

In an initial open trial, a case series investigation of the effectiveness of CAMS within this longer-term inpatient psychiatric setting found statistically and clinically significant reductions in depression, hopelessness, suicidal ideation, and improvement in relation to suicidal drivers for 20 inpatients (Ellis, Green et al., 2012). A second study at the Menninger Clinic found significant changes in overall suicide ideation and suicide-related thoughts.

How CAMS Helps Diverse Populations

As a flexible clinical framework, CAMS has proven to be uniquely adaptable and modifiable to meet the needs of different patients, providers, and systems of care in the “real world” of psychological services. This adaptability has lead to CAMS being used to help diverse patient populations from suicidal inpatient teenagers at Seattle Children’s Hospital to suicide-specific group therapy within VA health care settings, and even the California state prison system and juvenile justice facilities in Georgia.

A systems approach to suicide prevention has clearly emerged as the best means for raising the overall standard of clinical care for suicidal patients with the promise of saving lives. Zero Suicide is a game-changing policy initiative that is gaining traction in the U.S. and abroad.

We have presented a stepped care model of suicide that is designed to treat suicidal risk in an evidence-based, least restrictive, and cost-effective manner. Moreover, we have shown the potential value of applying and using the CAMS evidence-based approach across the full range of psychological services—from paraprofessional interventions, to outpatient settings, to respite care, to partial care, and to inpatient psychiatric care.

CAMS may not work for every suicidal patient or setting, but it is highly adaptable and effective for a range of suicidal patients across systems of clinical care. Given that suicide is the fatality of mental health care, we urge members in our field to do all that we can to enhance our abilities to effectively assess and treat suicidal risk across the full range of organized health care settings to help save lives.

Contact us to learn more about CAMS training and a range of applications for CAMS and the SSF for clinicians and providers across the world.

What Future? How People Who Are Suicidal Look Beyond the Present Moment

What future? How People Who Are Suicidal Look Beyond The Present Moment On-Demand Webinar

The consideration of suicide involves the contemplation of not only death, but also of life and what it can offer. This presentation explores cognitive underpinnings of life-oriented thoughts, with a particular focus on how people who are suicidal envision their future. Dr. Cha will introduce various ways to assess future thinking among individuals who are suicidal, and present an emerging profile of future thinking abilities that are characteristic of this population.

Christine Cha, PhD

About Christine Cha, PhD

Dr. Christine Cha is an Associate Professor of Clinical Psychology at Teachers College, Columbia University, and Director of the Laboratory for Clinical and Developmental Studies. Her research focuses on thought patterns that may contribute to suicidal thoughts and behaviors, and pertain to concepts proximal to suicide (e.g., death) as well as alternatives to suicide (e.g., future). Dr. Cha’s work has been funded by the American Foundation for Suicide Prevention and the National Institute of Mental Health (NIMH). She serves on the editorial boards of the Journal of Clinical Child and Adolescent Psychology, Journal of Abnormal Psychology, and General Hospital Psychiatry, and has received the Rising Star Award from the Association for Psychological Science.

Watch the Recorded Webinar On-Demand

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Cultivating Perspectives | Managing Suicidal Risk, 3rd Edition

Posted on by erics

Over decades of teaching clinical psychology Ph.D. students in graduate courses on clinical assessment, treatment, and theory, one inevitably develops certain adages. One of my favorites that is central to successful psychotherapy is the “cultivation of perspective.” In other words, successful psychological care invariably includes a series of shifts in perspective in relation to how the patient thinks and feels which shapes and guides behavior over time. While this notion is central to effective psychological transformation, I also find it relevant to writing books.

The 3rd and Final Edition of Managing Suicidal Risk

A couple of weeks ago, I submitted the 3rd edition manuscript of Managing Suicidal Risk: A Collaborative Approach, which is now going into production to be published by Guilford Press in 2023. This is the final edition of a series for the source book on the Collaborative Assessment and Management of Suicidality (CAMS). With this newest edition, I’ve now written seven books on suicide prevention & treatment, and may continue to write more in the future. But this 3rd edition is special and feels like a fitting end of a 30+ year journey. With four ongoing randomized controlled trials (RCTs) underway and new trials in the works, there will be more journal articles and book chapters about CAMS. But for me, the 3rd edition feels like a final concluding paragraph to a story that I have been writing across the course of my professional life. Completion of this manuscript also marks the end of a yearlong sabbatical from my “day job” as a university professor. I can attest that sabbatical leave is one of the single greatest perks within academic life. As a university professor one is always immersed in the ebb and flow of ideas, data, theories, and constantly shifting perspectives—these are the stock and trade of a scholar’s life. So, to step away from that life to immerse oneself in a singular focused year of reading, researching, and writing is a meaningful alternative reality. As this sabbatical concludes, I am awash in musings about life, death, suicide, hope, hopelessness, purpose, meaning, and what ultimately makes life worth living during these trying times in the world.

The History Behind the First Edition of Managing Suicidal Risk

In 2004 I was elated to land a contract to write the first edition of my book with Guilford. In those days, my SSF clinical research and the nascent development of CAMS was garnering some attention. I was thus eager to promote key CAMS ideas that were novel and controversial in some quarters at the time. For example, the overt goal within CAMS to keep a patient who is suicidal, out of the hospital was not a widely embraced idea. The idea of making suicide the singular focus of clinical care (no matter the diagnosis) was greeted with wary skepticism. Eschewing the use of no-harm contracts in lieu of focusing on stabilization was only beginning to gain some traction in the field at that time. My research mentor, Marsha Linehan, was dismayed that I wanted to write a book before I had definitive randomized controlled trial (RCT) support for CAMS. While there were articles about the assessment aspects of the SSF, there was only one modest non-randomized controlled comparison trial of CAMS with U.S. Airmen who were suicidal. While the data was encouraging, Marsha flatly reproached me, “…you’re jumping the gun, get some RCT data and then write your book!” On the heels of being admonished by Marsha, I reached out to Ed Shneidman—another seminal influence—who was extremely enthusiastic about the prospect of my writing the first book, and instantly offered to pen the foreword to the first edition. For the record, Ed was always keen about the writing of books! In fairness to my friend Marsha, she would have been right had I only written the first edition. But I argued that I could write about the work to date while also pursuing future CAMS RCTs. Marsha saw my point and was extremely supportive of all my efforts to fully test CAMS with grant funded RCTs. Notably, she readily agreed to write the foreword to the 2nd edition of the book published in 2016, remarking on the importance of two published RCTs of CAMS at that time.

The Evolution of CAMS

The 2006 first edition of the book was frankly my version of a “hard sell” for what CAMS could become, largely based on the strength of our SSF assessment research. And while there are still those who mistakenly think of CAMS as a mere assessment tool (focusing on the first page of the SSF’s first session), I’m only too happy to dispel the misconception. I am regularly encouraging people to catch up to the 2nd edition which presented CAMS as a major clinical intervention focused on identifying, targeting, and treating patient-defined “drivers” of suicide. The 2nd edition therefore made a strong case for CAMS being seen as a suicide-focused therapeutic framework increasingly supported by the burgeoning RCT support in the U.S. and abroad. As of this blog’s writing in June 2022, there are now ten published open/correlational trials and five published RCTs. Importantly, a 9-study meta-analysis of CAMS published 2021 marked a watershed moment in the development and empirical support of CAMS. There are two supportive CAMS RCTs now under review for publication, and four more rigorous CAMS RCT’s are ongoing. Needless to say, I took Marsha’s feedback to heart! Moreover, I would say in hindsight that writing that first edition clearly spurred interest in the approach and poured fuel on the fire of CAMS clinical trials by my lab and other investigators.

Perseverance and the importance of Clinical Trial Investigations

I share this not as a self-congratulatory exercise but as a testament to both perseverance and the importance of clinical trial investigations. At 63 I feel blessed to have had such success raising CAMS from its infancy, and nurturing and parenting it into what it has become today. For me, this work has always been first and foremost about the patients and their clinicians. Beyond this clear priority, the importance of scientifically proving that CAMS works has always been paramount. What we now know from clinical trial data is gratifying; in 6-8 sessions CAMS reliably shifts the patient’s perspective on suicide, creating a different way to think and feel about it, and experience life anew. The single biggest effect-size from the CAMS meta-analysis is the fact that CAMS significantly decreases hopelessness while significantly increasing hope (compared to control treatments). CAMS also reliably reduces overall symptom distress across clinical trials. In other words, CAMS does not necessarily eradicate every vestige of suicidality. Instead the data show that CAMS helps make the patient’s suicidal thoughts and feelings more manageable which makes them more behaviorally stable while it opens the door to consider life in a different way. When this occurs, it is a profound clinical achievement that clearly decreases suffering and can help save lives as well.

3rd Edition Highlights

Given all that has happened over the past 25 years, writing the 3rd edition has been a joy. I am delighted to have Thomas Joiner writing the foreword and it is a pleasure to report out what we now know about CAMS—how it works and what it does. The forthcoming SSF-5 has a few tweaks but much of it remains unchanged because of the extant empirical support it has garnered. One tweak is moving from an overall judgment of risk (mild, moderate, high) to a new clinical judgment related to concern about the patient’s relative stability (none, mild, moderate, serious, and extreme). There is a new Stabilization Support Plan (SSP) that can be used with significant others that complements the patient’s CAMS Stabilization Plan. There is further consideration of CAMS driver-oriented treatment planning and a major revision of the optional use of the CAMS Therapeutic Worksheet. There is further exploration of a “post-suicidal life” and a new optional Living Status Form (LSF) that completely mirrors the first page SSF used in the first session for successful CAMS outcomes. These are but a few highlights of the 3rd edition that includes an update of the clinical research literature, particularly the ever increasing CAMS-related studies.

Research is Hard, Expensive, & Endlessly Challenging

As I now reflect on the perspectives I have cultivated in writing the 3rd edition over the last year, a few observations surface. First, I am fortunate to have known Ed Shneidman, Bob Litman, Norm Farberow, and Jerry Motto—our founding fathers—who each influenced me deeply. The early support of Lanny Berman and giants in the field including Aaron Beck, Marsha Linehan, and Don Meichenbaum has been immeasurable. Second, there is nothing quite like clinical trial research. Studying a suicide-focused treatment is frankly harrowing; it is hard to do, expensive, risky, and endlessly challenging. Each study is a gamble; results do not always turn out as we would hope. Yet we always learn and find new ways to persevere based on what we find. And third, writing a series of books is a hell of a way to develop, support, and promote a new clinical intervention. Across three editions I have learned so much, and I have done my level best to translate that learning into helping patients who suffer and their providers who struggle to care.

The Cultivation of Wisdom

As I return to the classroom this fall, I will be heading into my final lap of my long academic run. Another seven years—one more blessed sabbatical—and then a transition into emeritus life and a well-earned retirement (God willing). Given the aches and pains, and various affronts of getting older, there are still certain virtues of becoming senior within our youth-obsessed culture. Among the virtues that rise to the top for me is: wisdom. In my view, wisdom is a remarkably underappreciated construct. In terms of perspective, wisdom is a pinnacle attainment within the pursuit of perspective-cultivation. Wisdom only comes with experience and the accrual of time; it is the operational culmination of an amassed perspective that is reflected in finely-tuning sound judgment. Wisdom is something that is best shared in a focused and measured way, always with a sense of patience and an experience-informed sense of timing. It often involves listening more and speaking less. But when words of wisdom are rendered, such words can carry the gravitas of a well-earned and valuable informed perspective. Simply stated, wisdom is cultivated perspective, par excellence! Having meaningful work, great love, and playing hard and well over the years all seem to contribute to an overall accumulation of experiential wealth that can directly inform one’s perspective and one’s sense of hard-earned wisdom. And apparently writing a few books along the way seems to help too! But for my part, with the time I have left, I will endeavor to listen more and speak less and endeavor to make my words count for the greater good.

“It’s Not About the Nail”: confession of a problem-solver

When I was initially being trained to be a Suicide Prevention Call Specialist, I found it difficult to not jump right into problem-solving with the Caller. My law school education and professional experience as an attorney immediately triggered a need to identify the underlying problem and solve it. I struggled with simply listening to the Caller’s challenges and not offering ideas to “fix” them.

I was fortunate to have an in-house expert help me with this. Dave suggested I watch a short YouTube video (1 min 41 seconds) that was popular in 2013, called “It’s Not About the Nail”. It uses comedy and an outrageous demonstration to convey how “problem solvers” can be distracted by “fixable” problems, and as such, miss or ignore the pain and frustration of the person they are talking to.

I am not sharing this to make light of anyone struggling with mental health issues, but as a resource to “problem-solvers” like myself who find it hard to grasp that our problem-solving skills are not always helpful. If you choose to watch it, I hope you find it as eye-opening as I did.

It’s Not About the Nail

Colleen Kelly Jobes
Former Suicide Prevention LifeLine Call Specialist
Loss Survivor