TCPR: Tell us about your approach to suicidality.

Dr. Jobes: It’s the Collaborative Assessment and Management of Suicidality, CAMS for short (Ryberg W et al, Trials 2016;17(1):481). We start by asking to take a seat next to the patient, both figuratively and literally. People who are suicidal may feel vulnerable and powerless with a mental health professional, and we want them to regain a sense of control in the therapeutic relationship. We share a clinical tool called the Suicide Status Form, where in the first session the patient writes out their responses to different quantitative and qualitative prompts. Together, we learn about the internal struggle that they’re having with suicide and why they think suicide might be a solution to some of their problems. We also collect information about their history, their thoughts of suicide, whether they have any access to lethal means, things like that.

TCPR: What do you do with the information?

Dr. Jobes: First we develop a stabilization plan. That’s not novel, but what is novel is that we ask the patient what makes them want to kill themselves. We ask “What do we need to treat to save your life?” Their answers are often about relationships and job struggles; their despair. We have college students saying “The earth is dying” or talking about racial and gender oppression. The patient is the expert of their experience, and the CAMS clinician rallies around that perspective.

TCPR: Do you ask the patient to estimate their own suicidal risk?

Dr. Jobes: Absolutely. We ask them to rate their psychological pain, their hopelessness, and their overall risk. Another novel part of the assessment is the patient writes out reasons for living and reasons for dying. They write out what they’re hopeless about. Patients really like that part. It conveys that they know best about their own struggle and puts their experience at the center of the assessment and treatment.

TCPR: Do you then look for ways to reduce their suicidal risk?

Dr. Jobes: Not exactly. Our focus is on reducing their suffering. We start by identifying why they want to take this drastic step.

TCPR: We’re taught that suicide is an irrational act. But in this therapy, there is a lot of validation. How do you walk that line?

Dr. Jobes: I don’t think suicide is necessarily a rational act, but it is an understandable act. I’ve never interviewed a patient who didn’t have legitimate needs and causes behind their suicidality. In CAMS, we ask them to hit the pause button, as in “Do you have to end your life to get your needs met?” We start with helping them build skills to survive the challenges they are facing, but over the six to 10 sessions of therapy, we shift our focus to reasons for living. We look for what would give them purpose and meaning.

TCPR: A useful question I’ve taken from your book is “What is one thing in your life that—if it changed—would make you not want to kill yourself?”

Dr. Jobes: Yes, that comes from Shawn Shea, who calls it the “miracle question.” People will say “If I could just get my meds right, I’d be fine.” Others want to win the lottery. Part of the therapeutic work is turning those ideas into realistic, concrete, achievable goals. Writing the answer down helps. It allows the patient to see their perspective from the outside.

TCPR: What do the outcomes for CAMS show?

Dr. Jobes: The biggest effect is increasing hope and decreasing hopelessness. CAMS also reliably reduces suicidal ideation and overall suffering. That comes from a meta-analysis where it was compared to other treatments for suicidality (Swift JK et al, Suicide Life Threat Behav 2021;51(5):882–896). It’s less clear whether CAMS reliably reduces suicide attempts, as there have been some mixed findings. There was a German inpatient randomized controlled trial that showed a significant reduction in attempt behaviors at one month post-discharge, but this finding needs replication (Santel M et al, BMC Psychiatry 2020;20:1–15).

TCPR: How do you manage the power dynamics around involuntary commitment?

Dr. Jobes: That dynamic begins to change when we say “Of course you can kill yourself. The issue is that as a licensed professional, I have to take steps to protect you if you’re in imminent danger.” That sounds provocative, and it has to be said in the right context to convey honesty and transparency. Similarly, we can say “About 130 Americans will have taken their lives by midnight tonight—do you have to be one of them? Or is there merit in seeing if we can treat what makes you suicidal so you don’t have to kill yourself? We all get to be dead forever, so what’s your hurry?” Instead of wagging my finger and saying “You can’t kill yourself,” I say “You can, but I can’t let you according to law. Can we find a way to not fight about that?”

TCPR: Are you also transparent about the fact that—ultimately—even hospitalization won’t entirely prevent suicide?

Dr. Jobes: Absolutely. We put all our cards on the table face up and hand the patient the clinician’s playbook. We don’t do the patient any favors by holding back the rules that our civil society has created to protect people from themselves. Laying it out like this gets us on the same team working for common goals.

TCPR: How do you approach suicidal thoughts?

Dr. Jobes: In our early clinical trials, the goal was for the patient to have no suicidal thoughts for at least three sessions. But in studying people who are living well after a suicide attempt, we often hear them say “Suicide is with me even though I’m doing well. I don’t see myself killing myself anytime in the near future, but I don’t necessarily want to get rid of these thoughts.” So my view on all this is evolving. I think that as long as patients are behaviorally stable and managing their thoughts and feelings, that is a successful outcome. But ultimately our goal is for them to pursue a life that’s worth living.

TCPR: Is suicide a comforting idea to some patients, as in “I always have an out”?

Dr. Jobes: Absolutely. For some people, it’s like a warm blanket. But for others, it’s like a hot potato they want to get rid of and they don’t know where to toss it.

TCPR: Do patients ever push back against the concept of hope, like it’s unrealistic Pollyanna talk?

Dr. Jobes: Yes. One way we learned this was from a Swiss study where we asked about reasons for living and reasons for dying. Clinicians were very excited about reasons for living. But in the two-year follow-up, we found the reasons for living didn’t predict any of the outcome variance (Brüdern J et al, BMC Psychiatry 2018;18(1):234). After a suicide attempt, most patients are focused on reasons for dying. So if I’m their clinician, it can be invalidating and even shaming for me to say “Well, what about your kids? What about your work? What about all the people who rely on you?” We now ask about reasons for living later, when the therapeutic alliance is in place and some traction in treatment has been realized.

TCPR: Sometimes when I ask about reasons to live, the answers sound like an afterthought, like “Maybe my dog.”

Dr. Jobes: Yes. That can be an empathic failure. What they are hearing is “You want me to have these reasons, but nothing is coming up, so they are for you, not for me.” That can change after a few sessions, though. We see hope coming into the picture and lean into it: “What would give you purpose and meaning? What would make your life worth living?”

TCPR: How do you get people to put the suicidality on hold and join with you to head in a positive direction?

Dr. Jobes: People with suicidal thoughts are ambivalent. I just point out the obvious, which is “People die by suicide. You can do that. So what’s the urgency? Why wouldn’t you do this treatment with me that’s helped so many people around the world, with everything to gain and nothing to lose? You can always kill yourself later. But if you’re going to be in treatment with me, you’re going to need to be all in. It does not work if you have only one toe in the water of treatment and the rest of you is attached to suicide. While you don’t have to do this treatment, if you decide to do it, you have to be all in to save your life.”

TCPR: How long does it take to get patients “all in”?

Dr. Jobes: I’ll say “Let’s give it six or 10 sessions and make an earnest attempt. You are probably here with me because you’re ambivalent, so maybe we should honor that ambivalence and understand that part of you that hasn’t already ended your life.”

TCPR: Are you comfortable treating a suicidal patient exclusively through telehealth?

Dr. Jobes: Absolutely. Expanding access to suicide-focused care has the power to lower the suicide rate. You’ll want to have thorough and thoughtful informed consent. Ideally you’ll also have a third party like a spouse, friend, or parent involved in case you need to contact them. A meta-analysis found that telehealth psychotherapy was as effective as face-to-face therapy for a variety of psychiatric conditions, and that it was actually more effective regarding cognitive behavioral treatments for depression (Fernandez E et al, Clin Psychol Psychother 2021;1–15). Recently, one of our clinicians was able to watch a patient get rid of their medication stash through a video session on the patient’s laptop.

TCPR: Tell us more about safety planning in CAMS.

Dr. Jobes: During interviews, people with lived experience of being suicidal have told us “Safety planning feels controlling and paternalistic.” In CAMS, we use a Stabilization Plan that is embedded within our suicide-focused treatment. We’ll talk about what the Stabilization Plan can mean for them, and how the brain changes during a suicidal crisis when the limbic system is highly activated and the prefrontal cortex that controls behavior goes quiet. Using one’s Stabilization Plan can help downregulate the limbic system and bring back judgment and behavioral control.

TCPR: How long does a suicidal crisis last?

Dr. Jobes: Some people ideate most of the day. Others have a low level of ideation that spikes when bad things happen. The spikes may be brief, like 60–90 minutes, but that amount of time can feel like an eternity. The CAMS Stabilization Plan (CSP) can help patients weather that crisis without any devastating action. The CSP should be written down, often on their phone, as they are not likely to remember it in that state of mind. In the CSP, we also talk directly about limiting access to lethal means and about people whom the patient can reach out to for help. We also use a tool called the Stabilization Support Plan for parents, spouses, significant others, or good friends to help support their loved one within a suicidal crisis.

TCPR: If a patient dies by suicide during treatment, do you meet with the family?

Dr. Jobes: A lot of attorneys will say “Don’t talk to the family.” But when you talk with the family instead of defensively circling the wagons with attorneys, it actually helps reduce malpractice suits (Mammen O et al, Gen Hosp Psychiatry 2020;67:51–57). Marsha Linehan, who developed dialectical behavior therapy, had a whole protocol when she lost patients. She would bring the family in and talk about their grief. She would go to the funeral. In the CAMS framework, we often bring the family into the early sessions. We’ve usually had a discussion with family about the hopes and limitations of suicide-focused clinical work, so they are not totally shocked by a tragic outcome. But it is always heartbreaking for all involved.

TCPR: Thank you for your time, Dr. Jobes.