The Collaborative Assessment and Management of Suicidality (CAMS): An Evolving Evidence‐Based Clinical Approach to Suicidal Risk

The Collaborative Assessment and Management of Suicidality (CAMS) is an evidence‐based clinical intervention that has significantly evolved over 25 years of clinical research. CAMS is best understood as a therapeutic framework that emphasizes a unique collaborative assessment and treatment planning process between the suicidal patient and clinician. This process is designed to enhance the therapeutic alliance and increase treatment motivation in the suicidal patient. Central to the CAMS approach is the use of the Suicide Status Form (SSF), which is a multipurpose clinical assessment, treatment planning, tracking, and outcome tool. The original development of CAMS was largely rooted in SSF‐based quantitative and qualitative assessment of suicidal risk. As this line of research progressed, CAMS emerged as a problem‐focused clinical intervention that is designed to target and treat suicidal “drivers” and ultimately eliminate suicidal coping. To date, CAMS (and the clinical use of the SSF) has been supported by six published correlational studies and one randomized clinical trial (RCT). Currently, two well‐powered RCTs are under way, and various new CAMS‐related projects are also being pursued. The clinical and empirical evolution of CAMS—how it was developed and what are the next steps for this clinical approach–are described here.     

A Psychometric Investigation of the Suicide Status Form II with a Psychiatric Inpatient Sample

We investigated the psychometric validity and reliability of the Suicide Status Form‐II (SSF‐II) developed by Jobes, Jacoby, Cimbolic, and Hustead (1997) . Participants were 149 psychiatric inpatients (108 suicidal; 41 nonsuicidal) at the Mayo Clinic. Each participant completed assessment measures within 24 hours of admission and 48–72 hours later. Factor analyses of the SSF core assessment produced a robust two‐factor solution reflecting chronic and acute response styles. The SSF core assessment had good to excellent convergent and criterion validity; pre‐post SSF ratings also demonstrated moderate test‐retest reliability. The results replicated previous research and show that the SSF‐II is psychometrically sound with a high‐risk suicidal inpatient sample.     

Determinants and Predictive Value of Clinician Assessment of Short‐Term Suicide Risk

We examine the interrelations among clinicians' judgment of patients' suicide risk, clinicians' emotional responses, and standard risk factors in the short‐term prediction of suicidal thoughts and behaviors. Psychiatric outpatients (n = 153) with a lifetime history of suicide ideation/attempt and their treating clinicians (n = 67) were evaluated at intake. Clinicians completed a standard suicide risk instrument (modified SAD PERSONS scale), a 10‐point Likert scale assessment of judgment of patient suicide risk (Clinician Prediction Scale), and a measure of their emotional responses to the patient (Therapist Response Questionnaire‐Suicide Form). The Columbia Suicide Severity Rating Scale and the Beck Scale for Suicide Ideation were administered at a one‐month follow‐up assessment (n = 114, 74.5%). Clinician judgment of risk significantly predicted suicidal thoughts and behaviors at follow‐up. Both the standard suicide risk instrument and clinician emotional responses contributed independently to the clinician assessment of risk, which, in turn, mediated their relationships with suicidal thoughts and behaviors. Our findings validate the importance of clinical judgment in assessing suicide risk. Clinical judgment appears to be informed both by concrete risk factors and clinicians' emotional responses to suicidal patients, highlighting emotional awareness as a promising area for research and training.     

Reasons for Living versus Reasons for Dying: Examining the Internal Debate of Suicide

The Reasons for Living vs. Reasons for Dying (RFL/RFD) Assessment was used to obtain suicidal outpatients' top five reasons for living and for dying, respectively. Forty-nine suicidal university counseling center patients provided 173 RFL and 145 RFD responses. These responses were organized into eight RFL coding categories and nine RFD coding categories. Two coders trained in the RFL/RFD coding system showed high levels of inter-rater reliability (K_RFL = .81; K_RFD = .80). Chi-square results for RFL and RFD coding categories showed that the coding categories were not equally salient to these suicidal patients.     

Counsellors' experiences of working with suicidal clients: An exploratory study

Counselling is increasingly available in a wide variety of contexts, including mental health and psychiatric services. As a consequence, counsellors increasingly work with clients who present with suicidal ideation, expressing either suicidal thought and/or intent in the counselling session. This paper describes an exploratory study that examined the experience of counsellors when working with suicidal clients. The paper considers counsellors' behavioural, cognitive and emotional responses to such suicidal expression, both on a personal and professional level. The research employed semi‐structured interviews. A constant comparative method was used in analysing the transcribed interview text. Results suggest that counsellors experience a range of responses when their clients express suicidal thought, including fear, anxiety, anger and professional impotence. The interviewees also expressed self‐doubts about their professional competence. In addition, they identified the threat of litigation for negligent practice and the lack of confidence in appropriate risk assessment approaches as significant causes for concern. The implications for further research, and practice, are discussed.     

The Practice of Suicide Assessment and Management by Marriage and Family Therapists

Abstract

Over 90% of mental health providers encounter suicidal clients. However, the majority of marriage and family therapists (MFTs) are not exposed to suicide-specific trainings within their clinical coursework. Due to the lack of consistent training protocols for suicide assessment and management among MFTs, this qualitative study identified common MFT responses to suicidal clients, including assessment of risk severity and intervention modalities. Responses were then compared to best practices for suicidal clients. Participants inconsistently adhered to best practices identified in the larger field of mental health, revealing the need for increased MFT training on suicide to ensure appropriate and effective care.     

Worst-point suicidal plans: a dimension of suicidality predictive of past suicide attempts and eventual death by suicide

Among 440 psychiatric outpatients with current suicidal ideation, we examined the empirical distinction between the “plans” vs. “desire” dimensions of suicidality, focusing for conceptual and empirical reasons on a worst-point assessment strategy. Factor analyses were consistent with the distinction, but more importantly, among the current ideators included in this study, the worst-point “plans” dimension was the only predictor significantly related to both of two important indices, history of past attempt and eventual suicide. These findings bear on the trajectory of suicidal behavior over time, as well as inform the clinical assessment of suicidal patients.     

An Ecological Momentary Intervention Study of Emotional Responses to Smartphone-Prompted CBT Skills Practice and the Relationship to Clinical Outcomes

The practice of therapeutic skills outside of sessions in which they are learned is one presumed key component of cognitive behavioral therapy (CBT). Yet, our understanding of how skills practice relates to clinical outcomes remains limited. Here, we explored patients’ emotional responses to CBT skills practice in a pilot study pairing smartphone-app-delivered skills reminders and guided practice (ecological momentary intervention [EMI]) using ecological momentary assessment (EMA). Participants (n = 25) were adults recently hospitalized for a suicide attempt or severe suicidal thinking. They received brief inpatient CBT (1 to 3 sessions covering core CBT skills from the Unified Protocol), followed by 1 month of EMI and EMA after discharge. On average, participants reported modest reductions in negative affect after skills use (i.e., immediate responses; median time elapsed = 4.30 minutes). Additionally, participants tended to report less negative affect when the timepoint preceding the current assessment included EMI skills practice, rather than EMA alone (i.e., delayed responses; median time elapsed between prompts = 2.17 hours). Immediate effects were unrelated to longer-term clinical outcomes, whereas greater delayed effects were associated with lower symptom severity at follow-up. Future studies should further examine how CBT skills use in daily life may alleviate symptoms.     

HIV infection and mental health: suicidal behaviour--systematic review

Suicide has long been associated with serious illness generally and HIV specifically. New treatments have affected prognosis in HIV positively, but it is unclear how they impact on suicidal burden (thoughts, self-harm and completions). This review examines all published suicide and HIV data for a definitive account of (1) prevalence of HIV-related suicidality, (2) measurement within studies and (3) effectiveness of interventions. Standard systematic research methods were used to gather quality published papers on HIV and suicide, searching published databases according to quality inclusion criteria. From the search, 332 papers were generated and hand searched resulting in 66 studies for analysis. Of these, 75% were American/European, but there was representation from developing countries. The breakdown of papers provided 12, which measured completed suicides (death records), five reporting suicide as a cause of attrition. Deliberate self-harm was measured in 21, using 22 instruments; 16 studies measured suicidal ideation using 14 instruments, suicidal thoughts were measured in 17, using 15 instruments. Navigating the diverse range of studies clearly points to a high-suicidal burden among people with HIV. The overview shows that autopsy studies reveal 9.4% of deceased HIV+?individuals had committed suicide; 2.4% HIV+?study participants commit suicide; approximately 20% of HIV+?people studied had deliberately harmed themselves; 26.9% reported suicidal ideation, 28.5% during the past week and 6.5% reported ideation as a side effect to medication; 22.2% had a suicide plan; 19.7% were generally "suicidal" (11.7% of people with AIDS, 15.3% at other stages of HIV); 23.1% reported thoughts of ending their own life; and 14.4% expressed a desire for death. Only three studies recruited over 70% female participants (39 studies recruited over 70% men), and six focussed on injecting drug users. Only three studies looked at interventions - predominantly indirect. Our detailed data suggest that all aspects of suicide are elevated and urgently require routine monitoring and tracking as a standard component of clinical care. There is scant evidence of direct interventions to reduce any aspect of suicidality, which needs urgent redress.     

Incorporating a Psychological Counselor in a Cancer Risk Assessment Program: Necessity, Acceptability, and Potential Roles

Evidence suggests that cancer risk assessment may be associated with increased psychological distress. This exploratory study assessed the necessity and acceptability of incorporating psychological counseling into routine clinic procedures at a cancer risk program. Following a visit to a university-based cancer risk clinic, patients (N = 102) completed an anonymous self-report instrument. Participants reported experiencing current stress and anxiety (41%), depression (29%), and suicidal ideation (2%). Patients with a history of cancer were more likely to be experiencing current emotional difficulties. Sixty-nine percent of the participants found the visit with the psychological counselor to be helpful, while 41% of the participants reported interest in follow-up psychological services. Interest in receiving future psychological services was positively correlated with levels of anxiety, depression, and cancer worry. This pilot study demonstrates the acceptability and potential role for psychological counselors in increasing adjustment in high-risk patients undergoing genetic counseling for inherited cancers.     

The utility of MMPI-2 suicide items for assessing suicidal potential: development of a Suicidal Potential Scale

The assessment of suicidal potential is one of the most challenging and stress-inducing tasks facing clinicians. Studies that have attempted to identify specific MMPI codetypes, scales, or individual items predictive of completed suicide have produced inconsistent findings. This study focused on the relationship between the six most direct MMPI-2 suicide items (Items 150, 303, 506, 520, 524, and 530) and verbally reported history of suicidal ideation and behavior among a sample of psychotherapy outpatients (n =116). These six MMPI-2 suicide items provided valuable information regarding suicidal ideation and behavior above and beyond that of verbal self-report. These items were grouped together to create a single scale, the Suicidal Potential Scale (SPS) that manifested strong internal consistency. The SPS provides the clinician with a reliable method of assessing for self-reported suicidal ideation and behavior.     

Dialogue as Constructivist Pedagogy: Probing the Minds of Psychology's Greatest Contributors

In this article, I report on my use of dialogue as an exploratory teaching tool in an undergraduate colloquium titled Historical Foundations of Psychology. Students completed written assignments in which they identified the contributors to psychology associated with each of a series of position statements that capture the intellectual, philosophical, or theoretical views of these individuals. Students were not told in advance the identity of contributors relative to their respective position statements, which assumed the form of excerpts and quotations (direct or paraphrased) from original and secondary sources. As part of their written responses, students provided supporting rationale for their answers and discussed the truths and misconceptions inherent in each statement. Afterward, students engaged in class discussion involving peer critique of their written responses. Through qualitative assessment, the dialogue method was shown to advance critical thinking and participation in the learning process. Students generally described dialogue as challenging, helpful, and enjoyable in exploring the views of eminent thinkers throughout the history of psychology. Findings are discussed in light of constructivist pedagogy, in which students actively and interactively create their own conceptual understandings. In line with the conclusion that dialogue is a promising instructional technique, future classroom applications are also presented.     

Writing characteristics of suicidal people on the Internet: a psychological investigation of emerging social environments

Three studies were carried out to investigate the writings of suicidal people on the Internet, hypothesizing consistent findings to equivalent research of offline writing. In Study 1, suicidal persons' (n = 34) attributions as the cause of their condition, as expressed in their free online writing, were compared to those of emotionally distressed, nonsuicidal (n = 16) and to nondistressed (n = 15) individuals. Results showed that suicidal persons have significantly more stable and global attributions than do the other groups. In Study 2, expressions of self-focus in online written messages were compared among suicidal, two levels of nonsuicidal but distressed, and nondistressed individuals (200 messages in each group). With the use of various expressions of self-focus, findings showed that suicidal people were distinctively self-focused in their writing, unlike their counterparts. In Study 3, psychologically relevant themes in the online writing of suicidal (n = 39) and highly distressed, nonsuicidal persons (n = 24) were compared. Results revealed that the former expressed significantly more unbearable psychological pain and cognitive constriction than did the latter. The findings of the three studies are consistent with those found in examinations of offline writing. The research has important implications for the use of online environments for psychological research and means for assessment, as well as for understanding suicidality.     

Mand acquisition across different teaching methodologies

Many children diagnosed with an autism spectrum disorder lack functional independent communication. The current study used a combined multiple‐baseline and alternating‐treatments design to evaluate whether the presence or absence of a verbal prompt (asking a question) during teaching affected independent verbal manding. Two teaching procedures were used to teach specific responses (two per teaching condition) and evaluate if the acquired response, once trained, occurred independently (in the absence of stimuli or supplemental prompts). One student learned more rapidly under the mand training condition whereas the other learned at a similar rate under both conditions. The assessment methodology presented may be beneficial in future practice to determine if one teaching procedure is more effective than the other for a learner.     

自杀意念高中生的社会信息编码特征

采用两因素混合实验设计, 以日常用词为实验材料, 选取不同自杀意念得分的高中生为被试, 通过三个实验考察自杀意念高中生的社会信息编码特征。研究结果发现:(1)自杀意念高分组被试对出现在消极词位置的探测刺激的反应时显著短于出现在积极词位置的探测刺激的反应时; 自杀意念低分组被试对出现在积极词位置的探测刺激的反应时显著短于出现在消极词位置的探测刺激的反应时。(2)在知觉加工水平上, 自杀意念高分组被试对消极词、积极词及中性词的回忆量之间无显著差异; 自杀意念低分组被试对三类词的回忆量之间也不存在显著差异。(3)在语义加工水平上, 自杀意念高分组被试的消极词回忆量显著高于积极词回忆量; 自杀意念低分组被试的积极词回忆量显著高于消极词回忆量。研究结论如下：高自杀意念高中生存在对消极信息的注意偏向和语义加工偏向, 但不存在知觉加工偏向; 低自杀意念高中生存在对积极信息的注意偏向和语义加工偏向, 但不存在知觉加工偏向。     

Sex-Typed Responses in the Rorschach Protocols of Children With Gender Identity Disorder

A coding system was developed to measure sex-typed responses in the Rorschach protocols of children with gender identity disorder (n = 79). Their responses were compared to that of sibling (n = 25), psychiatric (n = 26), and normal (n = 28) controls. Results show that children with gender identity disorder gave significantly more cross-sex responses than same-sex responses, whereas the psychiatric and normal controls gave significantly more same-sex responses than cross-sex responses. The siblings did not differ in the number of same-sex and cross-sex responses. Results are discussed with regard to various assessment issues in the study of children with gender identity disorder.     

Sex-typed responses in the Rorschach protocols of children with gender identity disorder.

A coding system was developed to measure sex-typed responses in the Rorschach protocols of children with gender identity disorder (n = 79). Their responses were compared to that of sibling (n = 25), psychiatric (n = 26), and normal (n = 28) controls. Results show that children with gender identity disorder gave significantly more cross-sex responses than same-sex responses, whereas the psychiatric and normal controls gave significantly more same-sex responses than cross-sex responses. The siblings did not differ in the number of same-sex and cross-sex responses. Results are discussed with regard to various assessment issues in the study of children with gender identity disorder.     

The collaborative assessment and management of suicidality versus treatment as usual: a retrospective study with suicidal outpatients

The Collaborative Assessment and Management of Suicidality (CAMS) is a novel clinical approach used to identify, assess, and manage suicidal outpatients (Jobes & Drozd, 2004). The results of a retrospective study evaluating the impact of CAMS versus treatment as usual (TAU) on suicidal outpatients are presented. Patients in the CAMS treatment group (n = 25) resolved their suicidality significantly more quickly than TAU patients (n = 30). CAMS was also significantly associated with decreased medical health care utilization in the 6 months after the start of suicide-related mental health treatment. These results provide promising preliminary support for the effectiveness of CAMS and a foundation for prospective research.     

Suicide and the Rorschach: A Rueful Postscript

A review of the Rorschach suicide literature written 10 years ago called for cross validation studies and the use of refined methodology in order to enhance the usefulness of the test as a device for the identification, prediction, and understanding of suicidal ideation and behavior. The present followup review was undertaken and it was concluded that careful and refined research methodology can somewhat enhance sensitivity of the Rorschach to suicidal activity. It was also concluded the replicative research has not supported previously promising Rorschach suicide indicators, suggesting that the Rorschach may be an inappropriate technique for assessing suicidal activity.     

The influence of cognitive emotion regulation strategies and depression severity on deliberate self-harm

Elaborating on previous studies on emotion regulation and deliberate self-harm (DSH), in the present study we distinguish between strategies of cognitive content (e.g., suicidal cognitions of perceived burdensomeness, helplessness, poor distress tolerance) and cognitive process (e.g., nonacceptance of emotional responses, lack of awareness of emotional responses). Young women who harmed themselves (n = 85) were compared with young women without a history of DSH (n = 93) across a broad range of strategies. Significant group differences were found for all measures, even when depression severity was controlled for. In addition, logistic regression analyses showed that both cognitive content strategies and cognitive process strategies made significant independent contributions to the prediction of group membership. Controlling for depression severity, suicidal cognitions, and nonacceptance of emotional responses independently predicted DSH. The strong association between suicidal cognitions and DSH seems to indicate the important role of these cognitions in recurrent and chronic DSH. The strong association between nonacceptance of emotional responses and DSH underscores the notion that DSH can be a way to avoid emotional problems. These findings are discussed in relation to recent cognitive-behavioral interventions and specific therapeutic techniques to further insight into how these interventions might work.