Adler School of Professional Psychology MFT LCSW Suicide and Grief Homework These Are two different questions and must be answered separately with a minimum of 200 words. The reading attached must be used to anwer the questions correctly. Answer must include 1 intext cite.
Question 1:Discuss two methods for preventing suicide and how you would integrate them with a family suicide watch?
Question 2:Describe how the CAMS approach and the ABFT model might fit together to make a hybrid model for addressing grief issues.
Video :Diamond, G. and S. Levy (2015). Attachment Based Family Therapy (ABFT) Webinar. Philadelphia, PA. Retrieved from http://vimeo.com/107753025 or https://www.youtube.com/watch?v=KcwHznzq-S4
See reading attached Psychological Services
2018, Vol. 15, No. 3, 243–250
© 2018 American Psychological Association
1541-1559/18/$12.00 http://dx.doi.org/10.1037/ser0000229
A Stepped Care Approach to Clinical Suicide Prevention
David A. Jobes, Mariam J. Gregorian, and Victoria A. Colborn
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
The Catholic University of America
Despite the enormous humanitarian and economic toll of suicide, mental health systems of care are
largely underprepared to work effectively with suicidal individuals and suicide is a leading “Sentinel
Event” in U.S. health care settings (The Joint Commission, 2016). 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 is yielding positive results (Hogan & Goldstein Grumet, 2016).
Along these lines, a “stepped care” approach developed by Jobes (2016) has been adapted and used
within the Zero Suicide curriculum as a model for systems-level care that is suicide-specific, evidencebased, 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 (Jobes, 2016). This article describes various
applications and uses of CAMS at all service levels and highlights CAMS-related innovations. It is
argued that 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.
Keywords: Zero Suicide, stepped care, suicide treatment, CAMS
mental health professionals work more effectively with suicidal
people. The work of this task force ultimately led to the publication
of a document entitled Suicide Care in Systems Framework, making a strong policy argument that the best approach to clinical
suicide prevention is a systems approach (National Action Alliance, 2011). From a patient-centric perspective, the task force
asserted that suicide risk should be screened and effectively assessed, tracked, and treated using evidence-based interventions
throughout a suicidal patient’s journey in a system of care. The key
ideas in this task force report subsequently led to the development
and launch of the Zero Suicide in Health and Behavioral Healthcare initiative (see: http://zerosuicide.sprc.org/). At the time of this
writing, 25 states in the U.S. have started developing state-level
Zero Suicide programs, as have 21 tribal Indian Health Services
authorities and urban centers. In the history of the field of suicide
prevention there has never been a broad-based policy initiative as
far-reaching and impactful as Zero Suicide has been over the past
several years (Hogan & Goldstein Grumet, 2016).
Data show that 9.8 million Americans suffer through suicidal
thoughts each year and 1.4 million make suicide attempts (Piscopo, Lipari, Cooney, & Glasheen, 2016). With over 44,000 deaths
per year, suicide stubbornly remains the 10th leading cause of
death in the United States with steady increases over the past
decade (Centers for Disease Control & Prevention, 2015). Given
the striking death toll and suicide-related suffering numbering in
the millions, there is an urgent need to develop broad and generalized approaches to suicide prevention efforts that have the potential to reach vulnerable individuals across various systems of
care.
A Systems-Level Response
In recent years, the National Action Alliance for Suicide Prevention has created 14 different task forces to help guide suicide
prevention at the national level in the United States (National
Action Alliance, 2011). Particular to the present discussion, the
Clinical Care and Intervention Task Force was formed to help
A Stepped Care Approach
As developed by Jobes (2016), a “stepped care” model for
suicidal clinical care has been adapted, modified, and integrated
into the Zero Suicide Academy’s core curriculum (designed to
guide implementation of this suicide-specific care policy). As
shown in Figure 1, health care costs on the Y-axis (ranging from
low to high), represent a major force that will likely drive future
suicide-specific care. In turn, from the bottom to top of the pyramid figure we see different kinds of services ranging from least to
most expensive forms of care for suicidal individuals (i.e., from
“free” crisis center hotline/text support all the way to expensive
inpatient care at the top of the pyramid). Each service layer in the
model reflects increasingly expensive care that clinical trial research has convincingly shown needs to be suicide-specific (vs.
diagnosis-focused; The Joint Commission, 2016). A major virtue
David A. Jobes, Mariam J. Gregorian, and Victoria A. Colborn, Department of Psychology, The Catholic University of America.
David A. Jobes would like to disclose the following potential conflicts:
grant funding for clinical trial research from the Department of Defense,
the American Foundation for Suicide Prevention, and the National Institute
of Mental Health; book royalties from American Psychological Association Press and Guilford Press; co-owner of CAMS-care, LLC (a clinical
training/consulting company). We thank our research collaborators over
the past 30 years who have made the work described throughout this article
possible. Special appreciation goes out to members—past and present— of
The Catholic University of America Suicide Prevention Lab.
Correspondence concerning this article should be addressed to David A.
Jobes, Department of Psychology, The Catholic University of America,
314 O’Boyle Hall, Washington, DC 20064. E-mail: jobes@cua.edu
243
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JOBES, GREGORIAN, AND COLBORN
understanding and treatment of the patient’s underlying suicidecausing drivers (Jobes, 2016).
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
CAMS First Session
Figure 1. From the bottom to top of the pyramid figure we see different
kinds of care ranging from least to most expensive forms of care for
suicidal individuals. The virtue of this model is the promise of driving
suicide-specific care that is: evidence-based, least-restrictive, and costeffective. Because CAMS is both a philosophy of care and a highly flexible
suicide-specific therapeutic framework, it can be readily applied and
adapted for use across each level of the stepped care model.
of the stepped care model is that it offers an approach to suicidespecific care that can be evidence-based, least-restrictive, and
cost-effective.
The Collaborative Assessment and Management of
Suicide (CAMS)
The Collaborative Assessment and Management of Suicidality
(CAMS) was developed as a suicide-focused clinical framework
that addresses various points raised thus far. CAMS is a phenomenological clinical approach centered on understanding a patient’s
suicidality (Jobes, 2016). CAMS is an evidence-based clinical
intervention supported by numerous empirical studies, including
correlational/open clinical trials as well as several randomized
controlled trials (refer to Table 1). CAMS is said to be “nondenominational” in that a variety of clinical techniques and therapeutic orientations can be used within the CAMS framework
(Jobes, 2016). CAMS neither dictates treatment nor the use of
specific theoretical approaches; it is best understood as a “philosophy of care” that focuses on the identification and targeted
treatment of patient-defined suicidal “drivers.” Suicidal drivers are
idiosyncratically defined problems that compel the patient to consider suicide as a means of coping (Jobes, 2016; Tucker, Crowley,
Davidson, & Gutierrez, 2015). Central to CAMS is a collaborative
assessment and treatment planning process, wherein the patient
serves as a “coauthor” of their own treatment plan (Jobes, 2016).
Collaboration and reciprocity help foster a strong therapeutic alliance, capitalizing on the patient’s invaluable first-person insights
which tend to enhance the patient’s motivation.
The Suicide Status Form (SSF)
The Suicide Status Form (SSF) serves as a multipurpose assessment, treatment planning, tracking, and outcome tool that functions as a clinical “roadmap,” guiding the dyad through the course
of CAMS-based care. The SSF helps the dyad in their evolving
The first session of CAMS is pivotal; it establishes the suicidespecific and driver-oriented treatment within a collaborative dynamic that is used throughout CAMS-guided care. Each session
begins with SSF-based assessment and ends with SSF-based treatment planning.
Assessment. During the first session of CAMS, the patient
and clinician sit side-by-side (with the patient’s permission) to
complete the first session version of the SSF together, which
consists of both quantitative scales and qualitative prompts for the
patient to write about their suicidal experience in their own words.
In Section A patients are asked to rate themselves on six key
constructs: psychological pain, stress, agitation, hopelessness, selfhate, and overall behavioral risk of suicide. The patient is
prompted to write in their own words qualitative responses for the
first five constructs—for example “What I find most painful is:
____.” The initial five constructs are also rank-ordered from most
to least important. Taken together, the six initial rating variables
make up the “SSF Core Assessment” which is revisited throughout
the duration of CAMS-guided care. There are additional questions
in the first session asking the patient to rate how much their
suicidal thoughts are related to feelings about themselves versus
others and the listing (and rank-ordering) of their respective reasons for living versus reasons for dying. Finally, the patient writes
a response to the prompt: “The one thing that would help me no
longer feel suicidal would be: ____.” Beyond these various quantitative and qualitative responses, Section B gathers specific suicide risk factor and warning sign information related to their plan
and access to means, their suicidal history, substance abuse, sleep
troubles, and so forth.
Treatment planning. CAMS treatment planning in the first
session (Section C of the SSF) focuses on the goal of keeping a
suicidal patient out of the hospital (if possible). To this end, there
is an initial focus on self-harm potential which prompts the completion of the CAMS Stabilization Plan (CSP) as the dyad collaboratively develops a plan that helps ensure the patient’s ability to
cope with current and future suicidal crises. Importantly, the CSP
is similar to safety planning (Stanley & Brown, 2012) and crisis
response planning (Bryan et al., 2017) and is not a variation of
“no-suicide” or “no-harm” contracting which lacks empirical support and may actually increase clinician liability (Lewis, 2007;
Rudd, Mandrusiak, & Joiner, 2006). After completing the CSP, the
CAMS treatment planning process identifies the two most pressing
problem-drivers (from the patient’s perspective). The clinician
then proposes goals for effective treatment and possible interventions to effectively treat each driver-problem. Patients are given a
hard copy of their CSP and completed SSF documents throughout
care (or they can take pictures of these documents on their smart
phone for between-session reference purposes).
HIPAA documentation. Under the Privacy Rule of the
Health Insurance Portability and Accountability Act (HIPAA)
there is an expectation that mental health professionals regularly
assess and document information pertinent to patient’s care (e.g.,
mental status, diagnoses, formulation of risk, and case notes)
within any HIPAA-compliant medical record progress note. A
A STEPPED CARE APPROACH
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Table 1
Empirical Support for the SSF and CAMS
Authors
Sample/setting
Jobes, Jacoby, Cimbolic,
and Hustead (1997)
106 College students,
university counseling center
Correlational
Jobes, Wong, Conrad,
Drozd, and NealWalden (2005)
Arkov, Rosenbaum,
Christiansen, Jønsson,
and Münchow (2008)
Jobes, Kahn-Greene,
Greene, and GoekeMorey (2009)
Nielsen, Alberdi, and
Rosenbaum (2011)
Comtois et al. (2011)
56 U.S. Air Force personnel,
outpatient clinic
Nonrandomized case-control
27 Danish outpatients,
community mental health
Correlational
55 College students, university
counseling center
Correlational
Significant linear reductions in overall symptom
distress and SI
42 Danish outpatients,
community mental health
32 Outpatients, community
mental health
Correlational
Significant pre-post reductions in SSF core
assessment ratings
Significantly greater reductions in SI for CAMS
vs. TAU; Significant improvements in hope/
optimism, overall symptom distress, and
patient satisfaction for CAMS patients
Statistically significant reductions in depression,
hopelessness, and SI; Significant pre-post
reductions in SSF core assessment ratings
N.S. between-group differences for self-harm and
subsequent suicide attempts for participants
treated with versus DBT (twice/week for 16
weeks) versus CAMS (8–10 sessions/week)
Between-group changes in SI and suicide-related
cognitions favoring CAMS versus PSM control
Ellis, Green, Allen,
Jobes, and Nadorff
(2012)
Andreasson et al. (2016)
Ellis, Rufino, Allen,
Fowler, and Jobes
(2015)
Ellis, Rufino, and Allen
(2017)
Jobes et al. (in press)
Design
Randomized controlled trial
20 Psychiatric inpatients
Open trial, case series
108 suicide attempters with
borderline features
Superiority randomized
controlled trial
52 Psychiatric inpatients
Controlled comparison
104 Psychiatric inpatients
Controlled comparison
148 U.S. Army infantry
soldiers, outpatient clinic
Randomized controlled trial
Results
Significant pre-post reductions in overall distress;
significant pre-post reductions in SSF core
assessment ratings
Significantly quicker reductions in SI for those
treated with CAMS versus TAU; significant
reductions in PC/ED visits with CAMS
Significant pre-post reductions in SSF core
assessment ratings
CAMS had significantly greater improvements in
SI, depression, functional disability, and wellbeing at discharge than PSM control patients
Robust effects for CAMS and E-CAU on all
primary/secondary measure; CAMS
significantly eliminated SI sooner than E-CAU
at 3-month follow-up (all treatment effects
were maintained at 6 and 12 months)
Note. SSF ⫽ Suicide Status Form; CAMS ⫽ Collaborative Assessment and Management of Suicidality; E-CAU ⫽ enhanced care as usual; ED ⫽
emergency department; N.S. ⫽ nonsignificant; PC ⫽ primary care; PSM ⫽ propensity score matched; SA ⫽ suicide attempt; SI ⫽ suicidal ideation;
TAU ⫽ treatment as usual.
final page of the SSF thus documents this information for each
session at each phase of CAMS to ensure that CAMS progress
notes within the medical record are both complete and thorough.
CAMS Interim Tracking Sessions
Assessment. Across CAMS-guided care, every interim session begins with the completion of the SSF Core Assessment and
ends with collaborative treatment planning in which the CSP is
improved as needed and the dyad endeavors to “sharpen” the focus
of the patient’s suicidal problem-drivers (Jobes, 2016). Although
suicidal problem-drivers are first identified in the initial session,
these self-identified reasons for suicidality may change in subtle or
dramatic ways as new insights and information are revealed over
the course of care. As the patient’s suicidal drivers evolve over
time, their treatment evolves accordingly.
Treatment planning. The emphasis of treatment during all
interim sessions is focused on the two problem drivers; interventions can be whatever the clinician deems are appropriate to treat
each driver (e.g., cognitive– behavioral therapy, psychodynamic
insight work, couples therapy, etc.). Although the model is agnostic and does not dictate the use of a particular treatment modality,
the model still offers several optional tools that may be used to
help treat common suicidal drivers (e.g., self-hate, hopelessness, or
perceived burdensomeness).
CAMS Outcome/Disposition Session
CAMS optimally comes to a close when criteria for resolution
are met (i.e., three consecutive sessions of low suicidal risk and the
successful management of suicide-related thoughts/feelings and
behaviors; see Jobes, 2016). For all clinical outcomes within
CAMS there is an SSF Outcome/Disposition form that is used
which documents the full array of clinical outcomes such as
resolution, unilateral termination, dropout, hospitalization, and so
forth.
Decreasing Malpractice Liability
The key for decreasing suicide-related malpractice liability is
providing clinical care that meets or exceeds the “standard of care”
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of what a reasonably prudent practitioner in a similar setting and
with a similar patient would do (Jobes & Berman, 1993). Malpractice litigation for “wrongful death” centers on three major
issues: (a) Was there sufficient suicide-specific assessment?; (b)
Was there sufficient suicide-specific treatment planning?; and (c) Was
there sufficient execution of the treatment plan? Beyond these considerations there should be professional consultation as needed and
ample documentation of clinical practices reflected within medical
record progress notes. Given the overt emphasis of suicide-specific
assessment, treatment planning, and tracking of risk to clinical outcomes with extensive SSF-based documentation all along the way,
using CAMS should help to significantly decrease exposure to malpractice liability in the event of a completed suicide (Jobes, 2016).
Training in CAMS
As discussed elsewhere (Jobes, 2016), it can be challenging to
change mental health providers’ practice behaviors to the use of an
evidence-based approach such as CAMS. Indeed, didactic training
alone may have limited impact on changing practice behaviors. As
successfully shown by Veterans Affairs trainings of evidence
based practices, a “blended” training approach (e.g., learners receive didactic content, engage in role-play training, and further
engage in coaching/consultation support as they use the new
practice) shows greater promise for changing clinical behaviors
(Smith et al., 2017). Given these considerations, authorized training in the adherent use of CAMS employs an integrated training
model that includes: (a) in-depth content coverage of the CAMS
model in a 3-hr online course, (b) a 1-day practical role-play
training, and (c) six to eight coaching/consultation calls. This
integrated training model is now being studied to optimize the
CAMS training experience within a cost-effective model (Jobes,
2016).
Applications and Use of CAMS Across the Stepped
Care Model
Because CAMS is both a philosophy of care and a highly
flexible suicide-specific therapeutic framework, it can be readily
adapted and easily used at each level of the stepped care model
depicted in Figure 1. However, one cannot assume that an intervention proven in one setting will necessarily work in all settings;
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