David Jobes on Collaborative Assessment and Management of Suicidality

David Jobes on Collaborative Assessment and Management of Suicidality

by Lawrence Rubin
Researcher and clinician David Jobes discusses what works and what doesn't when in the treatment of suicidal clients, and how to manage suicidality with his CAMS program.
Filed Under: Evidence-Based, Suicidality


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Hospitalization Rarely Works

Lawrence Rubin: Thanks so much for making time today for this important interview Dr. Jobes. Let’s just dive right in: What you think are the greatest challenges for clinicians working with suicidal clients?
David Jobes:
we’ve got a mindset that a suicidal person belongs in the hospital
I think the greatest challenges are the ones of our culture and of our mindset about what’s most helpful to suicidal people. I think we’ve got a mindset that a suicidal person belongs in the hospital and that you help a suicidal person by treating the mental disorder. I’m a clinician/researcher so I lead with my clinical eye, but I am very much interested in things that’ve been proven to work.

I don’t think randomized control trials (RCTs) are the only way to go--I think there are many true kinds of validity. But I am partial to RCTs because they give more clarity about the causal impact of things. And there are a lot of well-intended interventions that are surprisingly unhelpful if not actually harmful.

there’s evidence that hospitalization is actually harmful for suicidal people
To that end, I think we’re now seeing a period where the use of hospitalization is under the microscope. There’s evidence that hospitalization is actually harmful for suicidal people. There’s a psychiatrist in Melbourne, Australia who talks about nosocomial suicides, which are those caused by the hospitalization. Marsha Linehan, the developer of Dialectical Behavior Therapy (DBT) has for many years been very critical of hospitalization. I began my career in inpatient care and so while I’m not anti-hospitalization per se, I am when the treatment focus is exclusively on the mental disorder, and kind of skips the bullseye which is the suicidal thoughts and behaviors.

If you look at the literature, most of the hospitalization centers around well-focused pharmacological interventions and very brief stays of a few days. And the clinicians are not really asking important questions about the patient’s suicidality. These might include: Do you have suicidal thoughts? Can you tell me about those thoughts? Can we embrace a stabilization plan? And, there are different flavors of stabilization plans which have been proven to be more effective than no-harm contracts. We can ask questions such as: Can we talk about your access to lethal means? Can you think about the use of a lifeline and other resources? And after discharge, can the community do some psychological education that’s suicide specific and then can we institute some kind of follow up?

You know, I was thinking about this before our interview that, when I take my dog to the vet, I get a follow-up phone call the next day about how she’s doing. We don’t necessarily get that from mental health care. My dog gets a nice follow up phone call and I’m delighted to respond to those calls. But there’s evidence that different kinds of follow up, like a phone call, or a letter, or a postcard, or even texting can be helpful in changing behaviors.

we tend to think that medication is more helpful than it actually is for suicide risk. The evidence is at best, mixed
So, that’s one of my soapboxes! I’m really trying to get the focus on hospitalization shifted to suicide-specific considerations. And then in a related way, we tend to think that medication is more helpful than it actually is for suicide risk. The evidence is at best, mixed. We actually have existing treatments that are psychological in nature that most mental health people don’t know about or use routinely. 
LR: If hospitalization is a quick in-and-out and doesn’t focus on a plan upon release and follow up, then it can be as destructive as whatever the suicidal person brings in with them?
hospitalizing a teenager for a second time creates a more lethal trajectory of their suicidal thinking
I know for a fact that many clinicians, from the trainings that I do, are paralyzed by fear of litigation--malpractice and wrongful death tort litigation. This creates a defensive kind of approach to practice--a better safe than sorry approach. But patients get discharged very quickly from hospitals and there’s evidence that the post-discharge period is very high-risk of suicide. There’s actually a paper that was published in the Journal of Affective Disorders last year at the University of Michigan stating that hospitalizing a teenager for a second time creates a more lethal trajectory of their suicidal thinking. And it’s not that hospitalization, per se, is a bad thing. It’s just that we’re not focusing on suicidal thoughts and behaviors.
LR: So, suicidal patients are out of the hospital after this immersive experience where they have 24-hour care by a team of caring professionals. And then, boom, gone. And if there’s not some really positive powerful bridge, then they may be at even higher risk.
DJ: Well, I would even gently challenge the notion of a team of caring professionals. I think what the literature shows is that patients end up spending a lot of time watching TV in the day room, and they go to a couple psychoeducational groups that they don’t find especially helpful. And the only treatment that really exists is pharmacological. And a lot of the medicines, as you know, don’t really have a full therapeutic effect until weeks after initiation.

What we associate with hospitalization actually is not typically the case. There are of course exceptions. I don’t mean to upset people with the idea that every hospitalization experience is iatrogenic or negative. But I think there’s a fair amount of evidence that it’s not really meeting the needs of suicidal people or their families.

Clinical Conundrums

LR: How do clinicians cull through this massive literature in order to find their way to the most effective treatment?
we have a disconnect between proving an intervention works in a randomized control trial, and then actually disseminating and implementing that treatment
That’s a great question and challenge because we have a disconnect between proving an intervention works in a randomized control trial, and then actually disseminating and implementing that treatment. One model is Marsha Linehan’s DBT and the reason that DBT is so famous is that they’ve figured out the dissemination and implementation challenge.

It’s a very labor-intensive team treatment that clinicians can’t do on their own and it’s not for everybody. But if you want to learn about it, you can go to the Behavioral Tech website where there are training programs. The two empirically-supported cognitive therapy programs have effective treatments and associated books, especially for suicide attempters, but they don’t have training programs. And that’s a conundrum. You can’t really learn to do cognitive therapy for suicide prevention that was developed by Greg Brown and Aaron Beck at Penn or brief cognitive behavioral therapy (BCBT) developed by David Rudd and Craig Bryan, at the University of Utah, because these researchers haven’t taken their positive research findings to the next level. and developed a training component that clinicians can utilize.

On the other hand, research supported treatments like Acceptance and Commitment Therapy and some other really well-known therapies including cognitive behavioral therapy that are not suicide-specific. But paradoxically, there are training organizations that make it possible to learn these non-suicide-specific evidence-based interventions. In order to scale up a proven treatment and disseminate it to clinicians so they may learn it, you’ve got to have money to get to the corners of the world that you really want to have use this intervention.

So, for example, in our CAMS (Collaborative Assessment and Management of Suicidality) model and other well-disseminated models, there are books but also deep-dive online roleplay training components. Clinicians hate roleplay training even though it changes their behavior and is shown to be effective in terms of doing something different. And then a really critical element is the use of consultation calls to coach a clinician through a new treatment that they’re trying to learn.

We are in the business of training a lot of people all over the world and our CAMS model is gaining some traction, but a lot of what clinicians prefer in terms of training is not necessarily what’s going to change their behavior with suicidal clients, and that’s a real conundrum the field faces. 
LR: So, the challenge is bridging the gap between the research that proves treatment efficacy and disseminating it in a way that makes it likely that clinicians will effectively utilize it.
DJ: Right, and that’s a tough sell because a lot of us like to do what we know to do. I’m a middle-aged man, an old dog who doesn’t like new tricks, so I kind of get that. But in the case of suicide, it’s life and death. And you know, if the fallback is hospitalization or use of medication without support and there’s even the possibility that those might not be helpful, it’s incumbent upon us to do things that are effective.

clinicians need to be thoughtful about access to lethal means and having lethal means discussions with their suicidal clients
.And that doesn’t necessarily mean that clinicians working with suicidal clients have to learn adherence to intervention, but they do need to be thoughtful about safety planning and stabilization planning. Clinicians need to be thoughtful about access to lethal means and having lethal means discussions with their suicidal clients. These are examples of low-hanging fruit types of questions that any practitioner can embrace. There’s a task force that I was on that developed recommended standards of care for suicidal patients. And that’s available through the Suicide Intervention Resource Center and the National Action Alliance for Suicide Prevention. If clinicians just look up these organizations, they’ll see the low-hanging fruit that have an evidence-base and are relatively easy to incorporate into a standard practice.

The CAMS Program

LR: As a prelude to discussing your CAMS program, I’m interested to know how you developed an interest in suicide? Some clinicians stay away from suicide like the plague. Others run to it. You seem to have invested so much energy and resources in this topic over the years.
DJ: It was something I sort of bumped into. I was trying to get into a PhD clinical program and I wound up in a master’s program at American University here in Washington. My psychopathology professor was Lanny Burman, a leading figure in the field. I was really fascinated by his work in suicide, so he got me involved. I did my master’s thesis with him and I was of the cohort that got to meet the founders of my field--Ed Schneidman, Bob Litman, Norman Farberow and Jerome Moto.

I never felt comfortable having somebody promise they wouldn’t kill themselves
I was so blessed to meet the people that created my field, so I just stayed with it and I found out that it was my passion. Even when I was working early on in inpatient care or as a clinician, I never felt comfortable having somebody promise they wouldn’t kill themselves. That never made sense to me.] Early on, I started having some misgivings about the standard practices for suicidal cases and the seeds were planted to try to create something different that made more sense. 
LR: This leads me to your CAMS program which may not be familiar to psychotherapists in our audience who work with suicidal clients. Can you describe for those folks who might be interested in learning about and using it?
DJ: CAMS stands for Collaborative Assessment and Management of Suicidality. It’s not the typical intervention but instead a framework, a philosophy of care. The cornerstones of CAMS are that we’re empathic of suicidal states, collaborative with the suicidal patient, honest and transparent about the rules and laws about discussing suicide with a licensed provider who has statutes to follow, and that it is suicide specific.

The essential component of CAMS is the Suicide Status form--a multipurpose assessment, treatment planning, tracking and clinical-outcome tool. It consists of assessment, treatment and stabilization planning. Its major focus is keeping a suicidal person out of the hospital, which is a novel notion. But to do so, we have to develop a thoughtful stabilization plan. That means securing lethal means and developing a list of problem-solving skills or coping strategies and resources should a suicidal person get into an acute suicidal dark moment. And then a signature feature of CAMS, which I kind of chuckle at every time I say it because it seems so obvious, is that we ask a suicidal person “what makes you want to kill yourself?”

In CAMS, we call these reasons for wanting to kill yourself “drivers.” What suicidal people say when they are genuinely asked “what puts your life in peril?” are overwhelmingly treatable problems. They say things like: my wife is leaving me, I can’t live without her; I’m going underwater with my mortgage on my house and I’m going to lose it; I can’t get a job. Or they may be experiencing trauma from combat in Iraq. People have idiosyncratic problems that we have treatments for all day long.

We make the argument with suicidal clients that they’ve got everything to gain and nothing to lose by engaging in treatment. We typically see a positive response in six to eight sessions. But if you give us 12 sessions, we can probably reach a lot of what they’re struggling with and maybe give them a different way of coping with their situation than taking their life. 
LR: The buy in.
I also tell clients that they can always kill themselves later, which is true
I also tell clients that they can always kill themselves later, which is true. But there’s a reality, which is that as a practitioner here in Washington, DC, there are laws about clear and imminent danger, so you need to know the implications of being suicidal. We’re very transparent and clear about following the law with our clients but that we don’t have to fight over whether they can kill themselves or not. And for a lot of suicidal people, that is comforting and validating. It doesn’t feel shaming. So, there are a lot of aspects of this that sort of capture the imagination of the suicidal person.
LR: So, CAMS is s not a technique but a program that allows clinicians to use techniques from their own particular model, which you refer to as the non-denominationality.
DJ: Exactly. What we typically see is a strong therapeutic alliance because we’re not adversaries and not fighting with whether they can or can’t kill themselves. I let them know that “I’m going to follow the law, but I’d like to collaborate with you.” We literally take a side-by-side seating for certain assessment and treatment planning activities and give the patient a copy of their documents including their suicide status form and stabilization plan.

So, the tone we’re trying to set is to not be shaming, to not be invalidating, to never wag our fingers, to understand that for a person who suffers, this is a viable way of dealing with their situation. And to get our foot in the door to say, “why wouldn’t you try this out? I mean, we all get to be dead forever and I’m not debating whether you can or can’t kill yourself, but I am saying that the problems that you’re describing are treatable problems.”

And the agnostic aspect of it is that the therapist can be psychoanalytic, behavioral or humanistic, we don’t really tell people how to treat. What we’re asking of the provider is that they treat the problems that the patient says puts their life in peril. 
LR: How much of the actual implementation of therapeutic techniques would be occurring during the eight, nine, or 12 weeks? Or, do you use whatever technical skills you have that are theoretically driven during the implementation of CAMS? And then do you refer to a clinician after the CAMS period is over? What’s the timing like?
The idea is that if you’re suicidal, we’re going to tackle that and focus on that, and talk really about nothing else except the things that put your life at risk
We’re pretty much like a dog with a bone. The idea is that if you’re suicidal, we’re going to tackle that and focus on that, and talk really about nothing else except the things that put your life at risk. And so, that’s where I think the persistence bubble sometimes rubs certain patients the wrong way. While it’s meant to be a flexible and adaptive model in which we’re not telling clinicians how to treat, we remain focused exclusively on the suicide drivers even when clients don’t want to talk about suicide but instead something like the economy. Because unless it makes you want to kill yourself, we’re not going to really focus on that because we’re trying to take suicide off the table. And that persistence, I think, pays off. A big part of this is that we aren’t looking for somebody to eliminate any vestige of a suicidal thought. But when we wrap up CAMS, they’re managing those thoughts and feelings, and they’ve got a repertoire for coping differently rather than going to suicide as their first response.

And that’s held up well in the clinical trials as our operational criterion for resolution. And then all along the way what the CAMS model has extensive documentation, which is sort of the armor for litigation. People have tried to pursue malpractice lawsuits against CAMS providers, and to my knowledge, there’s never been a successful lawsuit because of the documentation. There’s no evidence of negligence around assessment or treatment planning or the clients falling through the cracks. So, that’s served very different functions in that the patient is a coauthor of their treatment planning. They see what their treatment plan is. They’re an active participant in developing their treatment plan. And we’re working with Microsoft to develop an electronic version of the Suicide Status Form (SSF) that mimics what we do by hand on our hardcopy because, of course, we have to work with electronic medical records. And we’ve got a prototype that will be fully developed in the spring that we’re testing at two medical centers to see if it interfaces with electronic records. So, we’re still working on it, and we still have clinical trials, and we’re learning about it as we go.
LR: What’s the evidence that CAMS is effective?
DJ: The big thing in science is correlational studies that are replicated. We have eight correlational published studies that have been replicated with basically the same findings. But that doesn’t really ring the bell. It’s randomized controlled trials that look at a causal impact. So, there are three published randomized controlled trials all supporting the intervention. There are two unpublished trials that are in review that have very supportive data. And there are three trials that are currently underway.

So, there’s a lot of replicated data showing that CAMS quickly reduces suicidal ideation, overall symptom distress, increases hope and decreases hopelessness. Patients like it and clinicians find it valuable. So, the data is actually quite robust. But as a clinician, it makes sense. At a lot of the trainings I’ve done over the years, people say, “you know, this just makes so much sense.” “You know, I’ve kind of been doing CAMS without realizing it.” And so, that’s always the greatest validation when a thoughtful clinician that says that CAMS worked with a particular client. So, it’s not just the research, it’s also clinical utility, a lot of which has been shaped by feedback from clinicians. 

Countertransference and Paralysis

LR: You write about countertransference with suicidal patients and how clinicians have referred to the experience of malice and hate along with fear and impotence. Can you say a little bit about some of the countertransference experiences that you’ve noticed and how clinicians who work with suicidal clients can effectively deal with these experiences?
DJ: I was dynamically trained and worked with a luminary in the field, John Maltsberger, who was at Harvard, and wrote the definitive and seminal work in countertransference back in 1974. It was a very famous paper about countertransferential hate and the suicidal patient. He didn’t waffle around and instead said that clinicians can hate these patients. And, what I think about that upon reflection is that you know they are threatening. For a lot of providers, it’s really scary to work with somebody who’s at the precipice and thinking about ending their life. It can be scary and anxiety provoking and a lot of providers are afraid of being sued if there’s a fatal outcome.

there’s a kind of head-in-the-sand mentality among clinicians around suicidality
But I also think there’s some data that backs up the idea that there’s a kind of head-in-the-sand mentality among clinicians around suicidality. They may think, I’m gonna kick this patient over to the real doctors who are the psychiatrists who see a lot more suicidal people than psychologists, social workers and counselors--it’s too much for me if I’m just a psychologist or just a counselor, and it’s over my head or I’m not competent. And my feeling is the ubiquity of the presentation requires some level of competence.

To me, it’s like an internist or a family primary care doctor saying, you know, I’ll give you a thorough exam, but I don’t do the heart thing. I mean, trust me on my competence, but I don’t really know about hearts. Because suicide and suicide presentations are very common, I don’t really see how a thoughtful and responsible clinician who aspires to be ethical and competent can say, “I don’t do this.” But the fear is significant. And it’s out there, and I get why people are afraid. It’s not like I relish these tough cases, but I feel like there’s a need to at least be knowledgeable about what’s effective and what we can do, which is actually a lot. 
LR: You mentioned the notion of paralysis that clinicians often experience along with anxiety surrounding work with suicidal clients. What do you mean by this paralysis, how does it manifest, and how can we help clinicians out there who experience it?
DJ: I think it’s a straightforward situation where the reality of malpractice tort litigation is important to understand. People think it happens a lot more than it does and that they’re a sitting duck if there’s a completed suicide. It’s a legal action where the burden of proof is on the plaintiff to prove that there was negligence in subsequent treatment and/or follow through. Both sides then hire experts. It’s a very unpleasant process, and I’ve been involved on both sides. But the reality is that if you’re doing thoughtful work and it’s well-documented, most plaintiff’s attorneys won’t take on the case because the documentation is so critical for these cases. And so, the plaintiff’s attorneys pretty much only take the cases on contingency, so they don’t get the big payoffs until they win or settle.

It doesn’t make the clinician bulletproof, but it decreases the likelihood of being successfully sued for malpractice for wrongful death. And then the other part, which is more up my alley, is the idea that there actually are treatments proven to work that have excellent evidence but are not widely used. These include dialectical behavior therapy and two forms of cognitive therapy that contain suicide-specific interventions. Each of these are highly effective and proof of their use, along with documentation, would greatly reduce the possibility of being found guilty of malpractice. 

Empathic Fortitude

LR: You said earlier that your back had been hurt by years of running and martial arts. I’m curious- do you see a connection between the strength that you have needed over your life to progress through martial arts and the strength that is needed to work with suicidal clients?
What I’m wondering is how have you brought your black belt qualities into this anxiety-eliciting and litigious clinical arena? 
DJ: [editquote;when we see a suicidal person as a threat versus being empathic of the struggle, we’re already creating an adversarial dynamic]I guess I don’t think of it that way. I guess there’s a courageous aspect to working with suicide, but I also think there’s just a commonsense-ness to it. When we see a suicidal person as a threat versus being empathic of the struggle, we’re already creating an adversarial dynamic. One of the things that I guess I have found in my experience is that when you tell a suicidal person DC mental health laws and rules regarding my obligation, I can simply say “this is what the law says.”

And when I say to somebody, “I can’t ultimately stop you from killing yourself and of course, this is something that you can do but I would hope that you don’t”, I essentially give them the playbook and put my cards on the table face up and let go of my illusion of control and power over this suicidal person. What I have found paradoxically is that it gives me much more credibility, influence and persuasive ability to offer this person a chance to find their way out of suicidal hell.

So, I appreciate the reference to courage but I think it takes a certain kind of empathic fortitude. I wrote a chapter with Maltsberger years ago that talked about empathic dread versus empathic fortitude. I thought of these dramatic kinds of notions of how out of empathic dread we would avoid working with suicidal clients or countertransference would take over. We’d get rid of these patients by hospitalizing them or transferring to another provider.

So, I do believe that there is a need for empathic fortitude I suppose. But at the same time, when you give the patient the playbook and say, “this is the deal; if you’re going to kill yourself today, I’ve got to call the police. I don’t want to do that, but I will.” You’re working with motivation. You’re working with paradox. You’re looking at counter-projection. And when you do it properly and thoughtfully and with a genuine heart and concern, most suicidal people in your office are relieved.
LR: I understand.
DJ: And they are suddenly less at risk. And, so I guess I discovered that empathic fortitude or courage helps, but being forthright and honest about the situation as it is decreases the tension in the therapeutic relationship dyad and can actually create motivation in the client.

Tailoring Suicide Treatment

LR: As I was watching your CAMS video, you referred to some clients having a love affair with suicide. What do you mean by this and how can a clinician identify it and address it?
clients who have been suicidal for a long time are at the point where being suicidal becomes a way of life--it becomes ego syntonic and comforting
What I mean by that is clients who have been suicidal for a long time are at the point where being suicidal becomes a way of life--it becomes ego syntonic and comforting. It’s like surrounding yourself in a warm blanket and snuggling in. I don’t mean that pejoratively or cynically, I mean it descriptively. And we’ve all seen clients like this for whom it’s comforting because they can control their crazy life by having something to hold onto. It’s become a part of who they are and becomes deeply internalized as a comforting thought.

That’s very different than people for whom it’s ego dystonic. They’re fighting the thoughts and they’re anxious. It feels like a hot potato they want to get rid of it, but they don’t know who to throw it to. And those are very distinctly different kinds of suicidal people. Our intervention responds to those people in different ways. And the thing I really want to emphasize is that not all suicidal people are the same. We’ve got relatively good data now of ways to stratify different kinds of suicidal states, and we’re getting into the research now where we can match different treatments to different states.
LR: Can you say a little bit more about this stratification of suicidal patients?
DJ: Yes, this is like the heart of the research we’re doing right now, which is looking at people who are upstream ideators. They’re relatively new to thinking about suicide. It’s kind of a hot potato, ego dystonic kind of experience. They don’t like being suicidal. It makes them anxious or it’s frightening. Or, people who are a little bit further downstream who are kind of on a teeter-totter of thinking, “well, you know, I don’t want to kill myself because I hate what that would do to my kids. But, I would love to flip off my girlfriend.” There’s an ambivalence in place that’s well documented in literature. And then there’s the final group that we’ve got reliable data on, who are chronically suicidal with multiple attempts, who are highly dysregulated and have this ego syntonic relationship with suicide.

The first two groups are pretty treatable quickly. That’s what we’ve seen in our trials. The suicidal types who are mostly attached to living, or the ambivalent types respond quickly to CAMS and other treatments. It’s not that the latter group don’t respond, it just takes more than six to eight sessions. In that latter group there are multiple attempters, or borderline personality disordered clients, or chronically suicidal people with a lot of dysregulation. This group is sort of the sweet spot for DBT. We’re doing trials right now looking at differences between CAMS and DBT for different kinds of suicidal states. We’ve got some promising, exciting data about those different states and then matching different treatments to different states.
LR: In my ethics class a few weeks back, I was discussing informed consent and its various components. The CAMS consent is very different from the traditional ones endorsed by the ACA or APA.  
DJ: Well, I teach ethics and I’m married to a lawyer, so I think a lot about medical, legal, and ethical considerations. And of course, in ethics, informed consent is a huge consideration which has been a dynamic area in the field of ethics in more recent years. What I say to a suicidal person is some version of "you can always kill yourself, and that’s always an option to you, but you’ve got everything to gain and nothing to lose by engaging in treatment.

if you are going to kill yourself in the next 24 hours, I may be compelled to hospitalize you, even against your will
But there are laws that say that if you are going to kill yourself in the next 24 hours, I may be compelled to hospitalize you, even against your will. And I don’t want to do that, I’d rather not go there. I’d rather not fight with you about this. So, wouldn’t it be comforting to know if you do kill yourself, that you’ve done everything in your power and within your control to make this life livable? I’m suggesting that this treatment would be in your best interest and may help you decide whether your life is indeed livable. You can always kill yourself later. But, if you’re going to kill yourself while you’re in the treatment, I’ll have to stop you.”

When I say that in a training, a lot of clinicians are shocked, but then I ask them to take the role of a suicidal person. When they put themselves in the place of a suicidal person, they say “wow, that’s actually really comforting and validating and reassuring. It makes me curious about why you’re saying this to me and what your real agenda is.” And I’m very clear with suicidal clients that my agenda is to find a way to save their life and to make it worth living.

What’s fascinating about it is that everything I said is 100 percent true--it’s the playbook. And to me, it’s the cards faceup on the table. I think it is life and death, and when we give up the illusion of power, we have much more influence and credibility with the client.

The Setback Session

LR: In the training video you demonstrate what I thought was a masterful example of a setback session as you call it. What do you mean by a setback session and can clinicians expect to have those and if so, how can they be constructive or useful moving forward?
DJ: We shot that training video in two days without a script. A clinical psychologist who had been in graduate school and worked in my lab picked a patient he had worked with during his internship and channeled him. And he was not a very easy patient as you probably saw. I want very strongly as a trainer for everything to go perfectly and never make mistakes. However, I am not a miracle worker so feel it is very important to model a setback.

So, when we shot this scene, we were kind of nervous because the client got upset with me and I got upset back. I usually try to be calm, cool, and collected but I kind of lost my cool. I was, however, able to regroup, recover and reassert the model. Contrary to our fears, that setback video, which was session nine, is wildly popular with the thousands of people that have done this training.

I had a guy come to me last week at a training and say, “I really liked the setback session. It was real, I could see myself, you know, in you. And I appreciate your honesty.” So, contrary to our fear that it would be me acting out or my countertransference getting the best of me, it was an example of not doing it perfectly, but then using it as an opportunity to regroup and to reassert the model. And in the final session when we get the outcome disposition, I ask the client what was the turning point, and he said, “well it was that session where I came in here, you know, ready to tear your head off and you got mad at me, but then we kind of coalesced around what didn’t happen. And that was the pivot point.” I don’t like getting upset but, you know, it was a real thing that we shot, and it’s turned out to be really a popular part of the training. 
LR: So, while it was not a real client in the training video, the setback session was helpful to clinicians?
DJ: In my trainings, a lot of people ask if he was a real client because it’s so intense and it’s so realistic. And when we do our roleplay trainings, we’ll go into a group of 50 or 70 clinicians and say, “who wants to play a client?” And then we will demonstrate sections of the CAMS intervention with somebody who comes out of the audience, where obviously it’s not pre-canned or scripted.

I think that’s why people like our training, because we practice what we preach and sometimes people play impossible cases and kind of act out a little bit. So, those are tricky. But for the most part, it’s pretty convincing if I’m demonstrating to you something that isn’t perfectly scripted out. And that’s how we do our training, all of our trainers will basically recruit somebody from the audience to play somebody they’re working with. And it’s a very convincing way to say yeah, you know, we’re taking the risk here to be successful or to fail at the model, but we’re going to assert the model and then you can see what you think, as a provider, that if this is something that you want to try to do. 

Suicide in the Rearview Mirror

LR: You had mentioned earlier that successful outcome is determined by three successive sessions in which the suicide risk on the Suicide Status Form is low. When does a client really turn the corner on suicide so that a clinician can have a greater assurance that they will not end their life.
DJ: That’s a great question because it’s always idiosyncratic. I’ll give you a case example that really kind of nails it. It was a soldier who was in the army and deployed in Iraq--an extremely unstable, traumatized service member. I watched his early videos which was one of our clinical trials. I would lie in bed awake at night thinking “this man’s going to kill himself and he may take out a few people in his unit along the way.”

He was a scary guy. But he got traction and we identified his drivers and we determined that he really needed to leave the military. We started working on his VA benefits, but he was having legal troubles and he had PTSD that we were able to treat as part of the CAMS model. What he later described to me was a perfect metaphor. He said, “when I first came in here, I was in the Humvee and driving towards suicide with no other place to go.” Later, he said, “I was driving towards suicide and kind of pulled up alongside of it, and then I passed it, and now it’s in my rearview mirror. I can still see it, but I’m driving away from it. And now I’m going to turn the corner and leave it behind.” And that, to me, just nailed it and captured what we’re looking for in our resolution session. It’s not somebody who doesn’t see it in the rearview mirror, but who’s determined to leave it behind and turn the corner.

that is what we’re after: somebody who says “killing myself is not the number one way to get my needs met
Metaphorically and literally, that is what we’re after: somebody who says “killing myself is not the number one way to get my needs met. I’ve got these coping strategies. I’ve got this support now that I didn’t have. I’ve got treatment for things that made me want to kill myself that are now approved. And I don’t have to do this most desperate thing a person can do, which is end my biological existence forever. I can press on and pursue a life worth living because I’ve seen that this is not my only option.” 

Closing Reflections

LR: I’ll ask you a question that you can choose to answer or not answer.
DJ: I’ll certainly answer.
LR: Has suicide impacted you personally in your life?
DJ: Oh yeah, I have had many suicidal patients. I had a patient as an intern at the VA Medical Center where I interned who I gave a Rorschach to who killed himself the next week which was devastating. I spent two hours with this man and he laid down in front of a bus in front of the hospital. I mean, it has hugely impacted me. I’ve had colleagues that’ve taken their lives. I haven’t had a psychotherapy case, but I don’t think I’m immune.

So, absolutely it’s touched me and touched people that I care about. And we’ve had three suicides in two different clinical trials. That’s devastating because we’re watching videos of these patients that we’re trying to save. And one in particular last fall was extremely painful. But we’re not going to not do this because the overwhelming flipside to that is that we’re in the lifesaving business. We get cards and letters from clients, and clinicians thanking us. There are hundreds of examples of both clinicians and patients who’ve said, you know, “this saved my life.”

And the reward of that far, far washes away the pain of the individual losses and tragedies that I
I’ve personally experienced, or that my team’s experienced. It is not everybody’s cup of tea, I get that. But my lab is a big group of students, and we are excited about our work and it’s not a morbid topic for us because we’re in the lifesaving business. And what we do translates into people finding a different way to live.

One of my favorite cases was a woman in Oklahoma who’d been suicidal for 20 years in. She got 43 sessions of CAMS, which is a lot of care from a really adherent provider. And when she reached the resolution session after 20 years of being suicidal, she gave the clinician a card and said something to the effect of, “thank you for believing in me. Thank you for persevering. I now think before I act. I’ve changed how I feel about myself and about suicide because CAMS spoiled the milk I used to drink.”
LR: CAMS spoiled the milk I used to drink. What did that mean for you?
DJ: I just love that because this was a way of life for her that’s now been taken away, but in the best possible sense because it means that she’s a mother to her children. She’s a grandmother to her grandchildren, and she is in the world and finding her way. She’s not perfect, but after 20 years of being attached to suicide, she decided to leave it behind.

That’s just an “N of 1.” But when I get that kind of feedback, it makes all the pain, or the fear, or the anxiety sort of wash away because what we’re doing is so helpful and redemptive in the best possible sense.
LR: You know, empirically-oriented clinicians look at an N of 1 and say, okay, great, go out and find me another 17 and we’ll consider it. But when you had an N of 1 such as this woman who was so impactful, that has so much meaning.
DJ: I embrace both the nomothetic and the idiographic, and I am a clinician-researcher versus a research clinician. So, the N of 1 idiographic approach and those testimonials mean a great deal to me. But I also believe in the power of data. And both I think are valid windows into what’s true in the world of clinical practice, and in this case, what is central to the business of trying to save lives.
LR: One final question I would ask is for our readers who are new to the field. What advice would you offer to those who might be interested in working in the area of suicide treatment?
DJ: That’s a great final question. I would say, to the best of your ability, you shouldn’t try to avoid these patients. You don’t have to become a specialist. But there are proven interventions and techniques that you can learn about from the National Action Alliance or from the Suicide Prevention Resource Center that are not a bridge too far. You can learn about stabilization planning. You can learn about how to ask about suicidal risk. You can learn about lethal means safety.

I would also say to them, you can learn about care and contact and follow up, and about the National Lifeline. And every clinician should be conversant with those ideas. And then there’s dialectical behavior therapy, two forms of cognitive therapy, CAMS, and several other interventions that have been proven to work in randomized control trials that need replication. There are treatments that are effective. And I always talk about all the treatments, not just my own, because I believe in the power of data.

there’s more than one way to be in the lifesaving business
I believe in things that are effective and that no one holds a corner on truth. And so, I’m always talking about the other treatments in some ways as much, or more so than my own treatment because I don’t think that there’s one way to do anything. There’s more than one way to be in the lifesaving business.
LR: Thanks, so much David.
DJ: You bet.

© 2018 Psychotherapy.net LLC

Supplemental Readings:

Jobes, D. A. (2017). Clinical assessment and treatment of suicide risk: A critique of contemporary care and CAMS as a possible remedy. Practice Innovations, 2, 207-220.

Jobes, D. A. (2016). Managing suicide risk, second edition: A collaborative approach. New York: Guilford.

Jobes, D. A. (2012). The collaborative assessment and management of suicidality (CAMS): An evolving evidence-based clinical approach to suicidal risk. Suicide and Life-threatening Behavior, 42, 640-653.

Jobes, D. A. Au, J. S., & Siegelman, A. (2015). Psychological approaches to suicide treatment and prevention. Current Treatment Options in Psychiatry. DOI: 10.1007/s40501-015-0064-3.

Jobes, D. A., Gregorian, M. J., & Colborn, V. A. (2018). A stepped care approach to clinical suicide prevention. Psychological Services, 15, 243-250.

Jobes, D. A., Rudd, M. D., Overholser, J. C., & Joiner, T. E. (2008). Ethical and competent care of suicidal patients: Contemporary challenges, new developments, and considerations for clinical practice. Professional Psychology: Research & Practice, 39, 405-413.
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David Jobes 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. He is also an Adjunct Professor of Psychiatry, School of Medicine, at Uniformed Services University. He has published six books and numerous peer-reviewed journal articles. Dr. Jobes is a past President of the American Association of Suicidology (AAS) and he is the recipient of various awards for his scientific work including the 1995 AAS “Shneidman Award” (early career contribution to suicidology), the 2012 AAS “Dublin Award” (for career contributions in suicidology), and the 2016 AAS “Linehan Award” (for suicide treatment research). He has been a consultant to the Centers for Disease Control and Prevention, the Institute of Medicine of the National Academy of Sciences, the National Institute of Mental Health, the Federal Bureau of Investigation, the Department of Defense, and Veterans Affairs. Dr. Jobes is member of the Scientific Council and the Public Policy Council of the American Foundation for Suicide Prevention (AFSP). 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, consulting, and forensic practice in Washington DC.
Lawrence Rubin Lawrence ‘Larry’ Rubin, PhD, ABPP, is a Florida licensed psychologist, and registered play therapist. He currently teaches in the doctoral program in Psychology at Nova Southeastern University and retired Professor of Counselor Education at St. Thomas University. A board-certified diplomate in clinical child and adolescent psychology, he has published numerous book chapters and edited volumes in psychotherapy and popular culture including the Handbook of Medical Play Therapy and Child Life: Interventions in Clinical and Medical Settings and Diagnosis and Treatment Planning Skills: A Popular Culture Casebook Approach. Larry is the editor at Psychotherapy.net.

CE credits: 1

Learning Objectives:

  • Create effective case conceptualizations for suicidal clients
  • Integrate the CAMSD protocol into your suicide treatment plans
  • Discuss the benefits and pitfalls of the CAMS program

Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here