Masters in Practice: Managing Suicidal Risk w/ Dr. David Jobes

Tune in to our latest Masters in Practice episode featuring Dr. David Jobes as he discusses his groundbreaking work on suicide prevention and the Collaborative Assessment and Management of Suicidality (CAMS) approach. Explore Dr. Jobes' journey in mental health and his passion for suicide prevention. Discover the core principles of the CAMS model, emphasizing empathy, collaboration, and honesty, and learn about its transformative impact on client empowerment. Explore the challenges to traditional approaches to suicide prevention and the crucial need for evidence-based practices. Dr. Jobes shares insights from the third edition of his CAMS book, including the positive outcomes reported by clinicians and patients alike. Delve into the collaborative treatment in suicide interventions and the potential of technology in the intervention process. Dr. Jobes underscores the importance of tailored treatments for different populations and addressing the underlying drivers of suicide. Join us as we uncover the hope and healing offered by the CAMS model and embrace Dr. Jobes' wisdom on seeking mentors, valuing honesty, and living with intention. We hope you enjoy this Masters in Practice episode: Managing Suicidal Risk w/ Dr. Jobes.

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Transcript

Masters in Practice: Managing Suicidal Risk w/ Dr. David Jobes
 Hey everyone, welcome to the Psyched to Practice Podcast your one stop for practical and useful clinical information. Masterful insights from experts in the field and a guide to Daily Living. I'm your host, Ray Christner, and with me Paul Wagner. And Paul. Today, we got to revisit a topic that we did in the past, suicide, but of kind of a different approach today. And lucky to have Dr. David Jobes on with us and now the previous focus being in schools and you know now you know that they've come on in was talking about CAMS, which is the collaborative assessment and management of suicidality. And, you know, we had a chance to talk with him about his recent book, Managing Suicidal Risk. It's the third edition of it and just a wealth of Information. And, you know, both in reading the book, but getting to talk with Dave as well. Like, it's just, you know, I just feel so immensely lucky, like getting the chance because I feel like it's changing my my thoughts on suicide and the treatment of it. Yeah. You know, I ran across Dave think about four years ago now and I saw him at a conference and really, you know, just in the couple hours he completely changed what I thought about suicide and how I am how I managed it. And, you know, it's and I think we hear this throughout the show a little bit, but it was really he just changed my perspective and I think kind of my take away kind of falls off of that. He actually uses the term that psychotherapy is perspective cultivation and I think it's a great little comment and he definitely changed my perspective and and how I practice. So, you know, four years later, it was great to actually have him on here and actually really talk about this topic. What was your take away today? I think for me, actually, it kind of plays off of what your what you're saying here, where the there's a beauty to the model, like Cam's model, where, you know, it's working to build and inspire hope for, you know, for the clients we're working with. And I think even early early on in the episode, he talks about stability. But there's, there's this other side of it that's kind of goes on like I talked about. But it's, it's a great way of building the clinicians confidence and comfort. And, you know, again, you know, in the episode we'll get into like just how challenging it is for for treatment, for suicide and, you know, how this model can really help, you know, provide a wider path for clinicians to follow that helps to build their confidence because so often there's a fear of, you know, liability. There's this fear of losing a client. And this is just kind of a nice way of approaching it and saying, hey, here's an approach that has evidence base and, you know, it's if. Worth trying out. It certainly, you know, I'm very thankful for the opportunity. Yeah, it was was really great. And for those of you who may not be familiar with Dave, Dr. David Jobs is a professor of psychology. Associate director of clinical training and the director of the Suicide Prevention Laboratory at Catholic University of America in Washington, DC. And I would love to hear your takeaways from this episode. I think both Paul and I kind of always walk away from these things thinking We have learned so much in that hour, so we'd love to hear what you've learned from this episode as well. And with that, we hope you enjoy this masters and Practice episode. Managing Suicidal Risk. So Dave, thanks so much for joining us today on the Safety Practice Podcast. We're so glad to have you with us. Delighted to be here with you guys. Well, so Paul and I are really excited to kind of talk a little bit about your work. And before we kind of get started, we always like to hear a little bit about the backstory of our guests. So tell us a little bit, how did you get into the field of mental health? I was thinking about this before my dad was I worked in Personnel, Human Resources back in the sixties and seventies, so that it's me right there. And he was involved in like early phase industrial organizational psychology. So he was doing grids, seminars and tea groups and sensitivity training and things that that were really, you know, sort of on the cutting edge back in those days. And he got Psychology Today. He got the magazine Psychology Today. And so I used to look at that as a kid, as a teenager, and think, oh, that's kind of interesting. So that was a bit of it. And then I went to college at the University of Colorado, and I was a philosophy major. And my favorite professor called me into his office and said, Get out of philosophy. There's no system. And I was lost. And then I was I was devastated because I imagined myself the next great philosopher. And I was I was at home in Cleveland during Thanksgiving break. And my best friend's dad, who know me since kindergarten, said, Well, of course, I became a psychologist. It's like, okay, I make friends. The rest is history. Wow. Yeah. It's interesting. We've had so many people that start in philosophy and then somebody says, Yeah, there's no jobs in that. Yeah, but what a great background that he does. I mean, I think, you know, philosophy's done so much for the field of psychology. It's kind of a great start point. So you could one could argue that philosophy is, you know, one of the one of the the grandparents of psychology. Yeah, I would agree. It's so moving into then kind of where you're at in your career now. So, you know, we're familiar with your work around suicide and specifically CAMHS. What led you down that path of work? How did you get into to the work around suicide? I was well, I went to college in Colorado and was not a very serious student. So I didn't do all the things that one should be doing in college to be competitive for a Ph.D. program, which is what I. Is that rather late in the game I wanted to pursue? And so I ended up went back to Cleveland. I worked in a children's hospital, I did research at Case Western Reserve University, and I literally went door to door to professors offices and said, Can I be a research assistant for you? And sure enough, a guy took me on, and so I started getting some research experience. And then I got into a master's program at American University here in Washington. And my psychopathology professor was Dr. Lanny Berman, and he was a luminary in the field, and he's now since retired. But he he kind of opened the door to the field. And at that time, I got to meet all the founding fathers and mothers of the professions I met each time and and probably met Norman, Barbaro, Marshall and Hahn and all these famous people that that are now sort of the founders and that that kind of did it for me. I got to meet the, the founders of my field and got really well mentored and, and then discovered my passion. I mean, this, this field is so compelling and we'll get into it, I'm sure. But I mean, I know people think it's a morbid topic and I say, you know, we're focused on saving lives and making lives worth living. And what could be more exciting than that in psychology or in anything, you know, from my bias. Yeah, I would I would agree. And, you know, it's interesting, you know, I had a chance to see you speak. Yes. It's been about maybe four years ago now. First National Practice Conference. And you're the first person that I heard talk the way you do about suicide work. And to really challenge this idea of inpatient hospitalizations and how we think a little different about it. And, you know, it's interesting that you said that, you know, it being exciting because I remember walking out of that going, okay, this is the first time I feel like there's a really hopeful path here. There's there's a way to think about suicide in a different way. And so I'm so excited to kind of dove into it a little bit and, and talk about your book. So I was excited to see you had a book come out. I've followed some things on your website and the CAMHS website and things, so looking forward to kind of diving into that a little bit. Yeah, I'm glad that was your takeaway because that that really is the goal is to really challenge what I would contend is like a medieval mindset about suicide and mental health, that this notion that people that are suicidal are crazy. The Latin would be non compos mentis, which means not in their right mind. And we had in the 1800s, 1900s, this mindset that if they were possessed by the devil, that's where we started. They were, they were, which is probably not much better, but they were they were crazy. And so so they had to be contained and controlled and sort of forced to come to their senses, which would mean that that they would no longer be suicidal. And so that's where we really. There are exceptions, of course, but that's where you're the moral response to a person that's suicidal is hospitalization and medication. And those interventions actually probably don't help that much and sometimes make things worse. Yeah. And it's I think it's one of the things I found kind of in my career. I think that when we jumped to that, we shut down the conversation. So, yes, people are so afraid that if I say I have thoughts of suicide, I'm going to go to the hospital. And so then they don't talk. And it's you know, so I think that's that when when I heard you speak, that was one of the things I was like, Wow, this is great. Because now we create a dialog with a person in a different way that they don't have to worry that that's we're going to jump to. And yeah, so I think, I think it's, you know, it, it's just a great way to kind of reframe. So maybe can you tell us a little bit about Cam's let's maybe kind of just tell us a little bit about that whole approach. Yeah. So that the, the, the pillars of Cam's are empathy, collaboration and honesty, which, you know, seems like it should be true for any psychological Treme. But what you're referring to is, is this mindset of like, get rid of this patient. You know, we got I've got to lock this person up, got to get medication in them because like, clinicians are frightened. And one of the reasons that clinicians are frightened is they don't get trained in what actually is effective to do with a person is thinking about suicide. What you alluded to is actually been proven empirically that there are there's evidence that patients in a prior practice study were reluctant to act by suicide because they're afraid to be thrown in the hospital. And then there a study that came out later that year showing that clinicians, number one sort of thing that respond to suicide with this hospitalization. And so we're kind of missing each other for missing our patients. The patients are missing us. And we're not, as you said, having a conversation about suffering and that that people are suicidal for legitimate reasons. And the question of cams is, do you have to end your life to get your needs met? And that's that's meant to be a very respectful question. It's meant to open the door to the patient or client to describe their experience. So a part of CAMHS, a sort of famous or infamous, is that we sit next to the patient with their permission. Because we want to get on the same team. So just like I'm looking at Paul and Ray here, you guys are a team. You know, you're sitting side by side and and that's sort of what we what we do in camp is we we try to get out of the adversarial sort of relationship. And move into a collaborative relationship. And what facilitates that is a document called the Suicide Status Forum or the SRF, and that's assessment, treatment, planning, tracking documentation, clinical outcome tool that has three different phases, but it's the roadmap that guides the process. We engage around this collaborative deconstruction of who, what, when, where, why did become suicidal, and then what can you do about it? And, you know, to go back to that point of just inviting the conversation and one thing like, you know, going through the book like I think it is and like the police, the first chapter and it's talking about the informed consent. And I was reading through that and I think you even kind of in a self-aware way, like write about it afterwards, about clinicians, responses of how they take that, the directness in talking about suicide and you know, that worry of like, oh, like sometimes it feels like a challenge because really it's like, you know, there's a finality that comes along with suicide. Why not give this evidence based practice a try? And I believe even in a later chapter, you know, sharing that piece where you're talking about how there's because evidence based, we need the buy in and so if they have that safety blanket of the stockpile of pills or firearm or whatever that you know, that that method is, if they're unwilling to part with that, then, you know, in a way they're saying, I'm not willing to give this, you know, a full buy in like that. I think I read the book. There's a lot of quotations section in the book. I encourage listeners to go and check it out because I think I read that three or four times and I was just like, wow, like such a so powerful. And, you know, I think you you talk about like trying to put yourself in the perspective of a client sitting a while sitting next to a clinician talking about this. And, you know, it invites it in in a way that makes it real, makes it a topic that we can talk about and work with. And, you know, it's just so valuable. Well, Paul, what I would say to that is when we give up the illusion of power over the patient, we gain much more influence and leverage. Mm hmm. And that's that's that's one of the secrets, you know, is that when we when we acknowledge that this person is capable of killing themselves. And by the by midnight tonight, I heard through two Americans who have taken their lives today. About a third of them have been in treatment with clinicians who don't know how to work with them. And the vast majority then don't want us. So that to me is is is a real commentary on the state of our field where upwards of 70% of people that die by suicide don't want mental health care. Why is that? Because what they get is something that's not empathic, not collaborative, not validating. And so, yeah, I appreciate your both you and Ray's take on this, because that's exactly the goal, is to sort of flip the tape, you know, flip the script and say, here are the ground rules I practice in D.C. and the District of Columbia and the Mental Health Act of D.C. and in Maryland, where I live, is very clear that you're in imminent danger. I have a duty to stop you from hurting yourself, and that might involve putting you in a facility where you can't leave for 24 hours or 36 hours, whatever the jurisdiction requires. I'd rather not do that. Wouldn't you rather not do that? Right. Some people want to go to the hospital and I don't know why, because it's not very pleasant experience, but with some exceptions, of course. But. So if we start, you know, trying to look at this through the patient's eyes, just as you said, and that this collaborative seating arrangement is a part of that, and I'm an old Rorschach marker. And in the when I first went to the university, I taught the Rorschach. And the Rorschach is inkblots that Hermann Rorschach made up in the early 1900s and showed the schizophrenic patients. And sure enough, they saw really bizarre and peculiar things. When we sit with the patient and go to the suicides to ask for them and really pay attention to what they're saying, the patient gets this like, wow, you actually are listening to me and you're actually care about what I'm going through. And so we know the answers serve as a therapeutic assessment. And then we have the audacity as we get into this to we do a stabilization plan, which is important. But but the real signature piece of CAMHS is we ask the client, What makes you want to kill yourself? And I've never had a patient say the lack of serotonin at the center class of the prefrontal cortex in neurons. They're like, my wife left me. My kids don't talk to me. I hate what I do. I'm for, you know, I'm foreclosing on my house. That's what people talk about who are suicidal. And that's what we target and trade in camps and in, you know, kind of going through the book. And if I could, you know, even just call it again, like, the book is such a great resource and, you know, the way it reads, it's if it feels like you're hearing the background of like the development, the conceptualization there. But it also feels like just such a great tool. And I, you know, I've spent quite a bit of time in the appendix flipping back and forth and just kind of really grounded myself. And I think it was a Cartman's example of like, you know, what that looks like in the, in the, the suicide status form. I love those six. Well, if the six areas or the six initial perceptions that you were talking about and I guess for for our listeners like you might kind of covering like what those six areas are initially. And then I know there's multiple steps and sections and the surf, but it really stood out. Support You refer to what we call the core assessment, and that's simply rating your psychological pain and stress and agitation and your hopelessness and self-hatred and your overall risk of suicide. And it's just a simple six step assessment that every session comes right to the resolution outcome starts with so the patient gets familiar with it, it becomes a working model in session for the patient. Come in and say, Well, I had a really great week this week and my pain is way down. But then my girlfriend threatened to leave me, so my hopelessness spiked. And, you know, it becomes something that's really valuable. Patients always get a copy of their self. So in all of our army studies, we had a soldier who would go home and put the stuff in the refrigerator and calls wife over. It would go through the treatment plan, update the up drivers and the stabilization plan, which is our version of a safety plan that's baked into the CAMS model. And we love this guy. You know, he was so into it and as and we bring his wife in and she was really supportive. He got in a debate with his clinician about whether his drunk drivers were really under indirect drivers. And and he was actually right. This clinician was wrong. But but what was so cool about it was that he was he was he was becoming his own suicide ologist. Yeah. And in CAMHS, we teach the patient to become their own suicide allergist to to understand that they're on their way to getting into trouble, which typically means that their limbic system and their amygdala is activated and their brain is on fire. And what's bad about that is that the prefrontal cortex shuts down, and we need this part of the brain because that's what that's what serve our judgment and our executive functioning and our empathy. A lot of good stuff is is offline. So if we can teach the patient that I'm getting into trouble, I should use my stabilization plan, or I should talk to my friend Ray, or I should call the National Lifeline or Text Line. Then we're doing things that basically reengage the prefrontal cortex to downregulate that part of the brain that's got over, over activated in that fight or flight mode. So all the evidence based interventions basically do the same thing. They teach patients what Aaron Beck referred to as a suicidal mode. There's other names for they teach patients when I'm getting in trouble and then what I should do instead. And it works. It's super simple, but it's actually it's actually a game changer. And in CAMHS, one of the things that's very unique about CAMHS is we don't eradicate every vestige of a suicidal thought. We just help the patient learn to manage those thoughts and manage those feelings. And she's something that I think is highly underrated, which is behavioral stability. So we're not necessarily angling for a cure. We're angling for management and stability. And we finish off the intervention focused on. What would make your life worth living? And I'm 65 and I'm looking at the last several years of my career here, and I'm really fascinated with what makes life worth living. What gives each of us a sense of purpose and meaning? And how do we understand, you know, what? What makes it worth getting up in the morning? Because it's not enough just to survive. And we would rather have people flourish and thrive. And not everybody can do that. But if they've been suicidal and they've got that brink. We want to back them away from that that brink, so to speak. Then it does open the door to possibilities. And that's the single biggest effect of CAMHS is increasing hope and decreasing hopelessness, which is a super cool finding that we're excited about. And you know, it's you used the word stabilization plan. And I have to say. Yeah, I'm sure that was very intentional in your you know, what a what a different change of thought moving from a safety plan which feels like some of these putting on you versus a stabilization plan that some of the teams with you and so is that simple just change a word I remember the first time that I either heard you say it or maybe I've read that terminology and I have found that patients respond to that. When you don't use it as simple as just that simple word change and say, listen, our goal stabilization here, this isn't a safety thing because I think, again, safety cues. Oh, you're going to you're going to lock me up. That's how you're going to keep me safe. And stabilization gives that okay, we're going to give you some skills so that you can manage this. And I love that you referenced about I'm going to keep this in mind about them being their own suicide ologist like know that because what an empowering. You know, just that simple kind of movement. What an empowering thing for people. That's great. Yeah, it's a new US thing, but it's actually a big deal, right? Because. Yeah, because we've. We've now done interviews with people who've lived, experience it. We've asked them about safety planning and you know, many of them are very positive about it. It's certainly better than what I grew up with, which has no harm contracts. Hmm. Promise me you won't kill yourself or block. You will remember those. Right. Right. People for you. Yeah. So people. I mean, I got to say, people still use them and think, oh, yeah, that's know, that's the state of the art. And it's not. It's been proven to be ineffective and three randomized controlled trials. But the thing about stabilization. Is we have this interview with this one woman who said, yeah, I did one of my four after our first attempt. And I felt very paternalistic and pejorative, like, we know you're going to eff up. So when you do, you need this thing. So I need for you to be safe for me. And she said that that was what landed with her. And she felt controlled and and disrespected. Now, that's not how Barbara Starr and Brown want people to do city planning, but it's oftentimes how it's done and because people are afraid and including clinicians. So clinicians have a hard time with this because they're afraid. They don't want to lose a patient. They don't want to be sued for malpractise wrongful death. So there's a lot of fear that goes into clinician actions that that doesn't help the patient. So when you flip the script and say, I can't stop you from killing yourself, but you are here with me now, why wouldn't we do this? You can always kill yourself later if you're going to kill yourself in an imminent kind of way. I got to stop you, you know? And that's what we mean by honesty and transparency, is that, you know, why wouldn't we lay all that out to get the patient or the client actual choices? And I don't know if if there's something you've ever looked into, but is you think that part of. Why clinicians kind of take this power approach sometimes with it is because of their own fear. It's like, I'm afraid this can happen, so we're going to control the situation. We're going to you know, I'm going to see it almost as parents when parents feel ill equipped and they they do these really harsh things that don't work. And it's almost like, you know, I always feel the same way with clinicians is they're so afraid that that's guiding them, making bad decisions. I couldn't agree more. I think it's yeah, it's very paradoxical and very problematic because of fear. Clinicians do this controlling things. And what I think about is like. Can you imagine going, you know, I survived cancer recently and I'm 100% cancer free. And so this is near and dear to me. You know, can you imagine having like four women breast cancer or colorectal cancer? So, you know, a form of cancer that that we're tens of thousands of people die just like suicide. And every pariah say, you know, I don't do a the evidence based stuff for the last 30 years. I kind of like the old stuff that we've been doing for 200 years. You'd be mortified. Yeah. You'd be mortified. And so one of the developments I'm really excited about is that we submitted a paper to the journal, American Psychologist, which for psychologists, the High Impact Journal is the big IPA Journal. And I actually expected a desk rejection because I just don't feel like there's a receptivity for these views. And basically, it was that we have an ethical and professional obligation to embrace evidence based approaches. They've been around for 30 years, and we really don't have an excuse. And not only was it not desk rejected, it got the best one of the best reviews I've ever received for a journal article. Wow. And I and I'm. I'm happy about that. But I'm. I'm excited because I think it reflects a kind of a tipping point where a receptivity that I don't think used to exist. And this is me being guardedly hopeful about, you know, shows like this and and and, you know, article like that or looking at these things in the sort of contrary way, has the potential to decrease a lot of human suffering. Mm hmm. 16.6 million Americans have serious thoughts of suicide. Wow. Yeah, that's. That's the population of Manhattan, New York City. Double it. And you're talking about how many people have serious thoughts of suicide. The United States in 2000, 22. This is all SAMHSA data. This robust data is 300 times greater than there. People die by suicide. And yet we don't think about suicidal ideation as a problem. In the UK kingdom you can only get dialectical behavior therapy if you make an attempt. If you only have suicidal thoughts, you get supportive counseling. So my friends there say that's operant conditioning to have people ramp up to an attempt behavior so they get beat, which is actually a incredibly effective treatment. It just makes no sense. So this is the this is the fight is why I'm so happy to be on your show is is just to say this makes no sense. You've got better ways to do this. Let's get over the fear and embrace our competency. And with competency comes confidence. And with confidence, patients change. And that's what it takes. And really and in a different way. But just as effective, I hear CAMHS is as much of a stabilization plan for the client as it is for the clinicians and being able to use it as a resource where they can feel confident, they can feel like, okay, when I'm afraid or when I feel unsure here. This is evidence based approach that I can rely on that has support and has research out there that I can turn to, that you know, can reproduce the effects of it. And so such a valuable thing. And, you know, certainly as you're sharing and talking, I'm thinking about my own, you know, just different trainings through your graduate program. And yeah, like we we talked about suicide, but not with suicide was. It wasn't his main focus. And one thing I really appreciate about Cam's is the way that it's framed as non believe that in the book you named it is non-denominational and it's only for suicide. We're not trying to think maybe there's adaptability, but that's not what we're looking for. We're looking to, you know, the point of Cam's is to decrease those suicidal the suicidal ideation and increasing hope. And I think it's absolutely brilliant. Well, we kind of backed the kind of back clinicians into becoming comfortable with this topic. And so you really pick up on that subtly, Paul, which I appreciate, that it is about managing the suicidal risk for the client, but it's also managing the clinicians anxiety as well. When I was first in the field, I wrote this chapter with this very famous guy, John Musburger, and it was called The Hazards of Working. He Hazards of Working with Suicidal Risk and. I had this thing that I wrote about empathic fortitude that I thought was so clever. And the therapist voyeur, you know, who who's on the outside looking in. All very professional, but not really engaged. And but with empathic fortitude. You know, we can we can become a therapist participant. And, you know, I just love this. And I would go and present to people and they'd be like, Yeah, no, you know, just empathic fortitude. Like we didn't want to hear about the other. And so I think quite literally. Insert, getting someone to sit down next to the patient and then look at this document. It's a stimulus field, but it also puts us on the same team and the patient feels very validated and very taken seriously. And they get copies of these documents and they at the end of every session, we go back to your treatment plan and say, okay, Paul, you know, your drivers are you know, that you are socially isolated and that, you know, and your issues. Are these still your issues or do we need to modify these? So you're a coauthor of your own treatment plan. And so it really it really mixes things up, especially with the expectations that are out there. As you guys have been alluding to. It's so much better than what is typical. And it's in some ways so simple, which is kind of the beauty of it. It's just like really listening to somebody who suffers in this way is the most therapeutic thing you can do. And not getting rid of them is also super therapeutic. And if we made it a therapy, then it then the analysts wouldn't like it or the cognitive therapy therapist wouldn't like it. So the idea of making a framework was was compelling because then you could be an analyst or you could be and you could primal scream. We don't really care what your theoretical bent is or what techniques to use as long as you're using the framework and treating drivers. And patients like it. You know, I had a student who's training at a clinic here in D.C. and and she was asked to do a presentation on cams for the for the staff. And one of the senior clinicians like. Oh, that's so cold and harsh. You know, and it's like what is opposite of coal is cold and rigid. And people think of the forms as being this rigid thing, and they think of Cam's always assessment it's a full blown, grown up treatment. Yeah, seven randomized controlled trials and two meta analysis supporting it. And so people are not up to speed. They are they don't necessarily they might be still in the first edition. That third edition that you're referring to really is the capstone of the of the intervention and not the work out on this. And the other thing you allude to, I'm kind of going on here, but the other thing you learned through my editor at Guilford really wanted me to write the book in the first person. And I initially resisted that. As you know, that's not how an academic writes. You know, it's always third person. He was 100% right. And I think what you alluded to and the readability of it and a lot of the self disclosures I make in the case examples really helps. Helps the cause and makes clinicians perhaps a little bit more comfortable with the whole concept of working with this issue as well. And I am not sure. I don't recall seeing it, but that doesn't mean that it wasn't there. But is there any data on clinicians rating of comfort in engaging with clients with suicide kind of prior to and then after going through the treatment process with CAMHS and then being able to use it and experience it with clients. Like is there any data there that shows their confidence and comfort? There is with engaging with the topic. Yeah, there's there's actually multiple studies. There was a study in Georgia about people engaged in CAMHS training and how much more confident and competent they felt. There's a study that we did was published in the journal Affective Disorders about clinicians feeling significantly more competent and competent in using cams. Yeah, there's a fair amount of clinician data over the years and you know, and what's what I find really exciting. We have three randomized controlled trials going right now funded by and image and that were this the pre-COVID and one of the things is that we've now been able to do cams online we have I feel able PD off at the south and we can do it under oximeter or Zoom or whatever secure platform our clinician uses It works great. The clinician is now the scribe and they're and the patients is exactly what you're putting on there a safe and they still get a copy. They love correcting the condition, which is fun to watch. But but the other thing I was going to say about that is that the we see the comfort that clinicians get in of having something that works. Mostly to the reactions of the patients and help out that the patients are. So we started out these trials with license providers like at this campus trial for university counseling centers. Now, 100%, maybe one exception of the clinicians are people in training of our VA randomized controlled trial was 100% graduate students. And they're great. They believe in evidence. They don't want to screw up and they want to be competent and they don't have add ons like my age do. So we love training young clinicians because they're just all about it. I think I remember I don't know if you had said this or where you guys have tried one with an avatar as well. Right. Isn't there a Dr. David Jobs avatar existing out there somewhere? The doctor did have things out in his face now. Okay. Because the people do experience like get rid of the old guy. So we abattoirs are very expensive. So this is the Jasper, this is the Jasper Health Intervention. That's an immersive based intervention where a lot of elements of cams are part of this tablet engagement. And the, the, the relational agents are called Jasper and a little cartoon person called, called Jasper and a woman of color named Jazz. And it's a it's a menu driven experience where you get a lot of the self assessment, but you also can watch puppies playing or learn about diplomatic breathing or tune in to stories of people that have experience talking about how they recovered. And so we've done two and I made a funded grants that Dr. Davis That was the proof of concept study and it went well. But this is up the Jasper intervention is is much more robust and patients like it better. And what's interesting about it is how much do people like being the first department? Not at all. How long do they wait to see their doctor? Eight, 15, 24 ordered overnight hours. And and so while they're sitting there, why not let them engage with this with this intervention and what they like they can download on their smartphone So it's been a really cool line of research. Linda Namath and Kelly Kerner with a collaborators that and we're still doing research with it and it's it's it's a part of the solution because Ed visits are miserable and they're typically not very therapeutic for our mental health patients in particular. You know, this is a little outside of Cam's. But, you know, I keep reading things about these these kind of I interventions as a a screening or maybe a starting point for someone who is, you know, maybe feeling like they're they're going to make an attempt or whatever it might be. What are your thoughts around that use of technology as as a starting point in the intervention process? I am open and supportive of anything that's going to help the cause. So I'm not just Cam's. I'm ambassador to the field of what works. Mm hmm. So our training company has webinars. I just have Matt McCown from Harvard, and Matt's all about technologies and ecological imagery assessment, which our assessments are on your phone. There's a number of chat bots and there's a number of technologies that are being developed along these lines. You know, 16.6 million Americans with serious thoughts of suicide. We've got to do something and we will never have enough commissions. So I'm a big fan of peer based interventions, of paraprofessional models. I've been known to advocate a mental health service core, which would be like a mental health Peace Corps type of movement and the technologies. It's not the solution, but it's a part of the solution, I'm convinced. Yeah, it's. Yeah, I kind of feel the same way. I think it's it's great to see that there are people thinking outside the box to try to, you know, try anything. Because, as you know, we live in an area in Pennsylvania where we're in a shortage. I mean, I know there's a national shortage, but, you know, we're struggling to get people in any any way that we can kind of intervene earlier. I think so. Wonderful options, Matt. Matt not, for example, did this really cool study on a platform called Coco. And when people post provocative messages about maybe suicidal, there's a sort of an automatic intervention. And a lot of a lot of social media platforms are sort of working with, you know, giving the nine, eight, eight number or the national text line number. And Matt did this really cool study where they created up an automated way of saying, okay, right. It sounds like you're you're not doing too great. Here's the National Lifeline number. And you would you would then have that resource and then they would say, are you going to call? And like most Americans, you say no and say, why don't you get a call? Well, I don't want the police coming. The police only come. And 1% of the calls of all the calls to the national lifeline. So and they were actually able to demonstrate that people actually increased their calling behavior. Through an algorithm and a file and file and following up, you know, just sort of like pushing, you know, sort of the common questions or come coming, push back and you think about it. Clinicians like without thinking twice about will leave you know the lifeline number on their on their they're they're they're recording they're very worried for their office or take yourself to the nearest emergency room. Mercy rooms are not therapeutic and most people are not going to call the lifeline. But you know but go you know, left that message on my phone and and it's that it's just it's better to do that than nothing. But it doesn't it doesn't map on to what people who are suicidal need and are. Actually, I do. So I just wanna make sure I'm hearing this right then so that that program you were saying it was the fact that they gave them the information that 1%. Actually the police come that changed calling behavior. That's that's one anecdote from that. But they had they had an incredible. Yeah. They had a number of like what what is your reason for not calling Lifeline? And they had sort of factual based information to get back to you. So it was a a couple of interactions, but it was all computer driven. And it change behavior. I mean, what a what a powerful thought. I mean, even just for clinicians, it goes back to how we started, right? I mean, if the person fears that, that's what's going to be the outcome, we shut down the conversation and that's how it's to me and I've never heard that research. It's super interesting. He does a lot of really clever things. So I mean, that really cool that that to me is exciting and and so and we need all of it, you know. And so that's why, you know, I really do talk about the other inventions and not just cams. Cams is the best intervention for the biggest problem, which is the 16.6 million. Yeah, but the other interventions are better with attempt behaviors. We've got some attempt data, but we need to replicate that data. And there's an interesting bifurcation of that, of the proven treatments like dialectical behavior therapy or the cognitive therapy interventions that are suicide focused They reliably reduce attempt and self-harm behaviors, but they don't move the needle on ideation. Rick Hammes always moves the needle of ideation. Attachment based family therapy reduces ideation, but doesn't necessarily reliably reduce attempt behaviors. So so I've written a paper. One size doesn't fit all. I mean, we really do need to match different treatments to different kinds of populations. And we are in a place where that is possible. We just have to have the the will and the administrations and the systems of care buy into that model. I'm working on editorial with Julie Goldstein Grumet, who's the the leader of the Zero Suicide Movement. And Zero Susan has been this very successful policy initiative to raise standards of care for suicide risk across systems of care. There are 12 components. The treat component is largely ignored. There's good leadership. There's the pathway. There's screening there. Safety planning. There is post fashion but treat this can't skip over the treat I did at Columbia. I gave them a safety plan. We're good, you know, and that is a good start. But that doesn't treat what makes this person consider ending their life, which is is to me, you know, it's the vitality of our feels. How can we not be about that? And yet, as we've been discussing it, a lot of clinicians just don't want to go there, you know? And, you know, we kind of used the term earlier about wanting to connect that to like the treatment process, which is like the drivers. And really that that was, you know, reading through and recognize like that familiarizing with the cams model like that was that focus of if we can understand and identify and then understand the drivers empathically, then we can work, you know, again, engaging that prefrontal cortex in terms of the problem solving and really working to say how do we how do we change this and create a measure of of hope in them? And I guess with that, like, well, would you mind kind of sharing just a little bit with our listeners like those drivers, like how do like how does that identification really, really kind of shine with the treatment process, like the connection between those two? Yeah. I mean, I love this concept because for people who are suicidal, they say really if they feel driven, yeah, psychological driven to do this and it's like not under the control. And, and so one of the things that we know about that is that so, so much that driver content is relational by far is the number one kind of driver that we see. There's a fair amount of we published a paper last year on this, a fair amount of vocational struggle. People hating what they do, how they spend their time, how they make their living get by and life. There is some measure of suffering and struggle. And what's interesting about treating drivers is you do not have to treat them and eliminate them. You just have to make some progress. Yeah. And with progress, there's hope and there's hope. Anything's possible. And so that that's that's the thing that I'm that I really am excited about is that we did a study in Switzerland looking at reasons for living, reasons for dying, you know, thinking that reasons for living were protective protective factors. And in the sort of two year follow up and reasons for living didn't do anything. In predicting outcomes. It was all about reasons for dying. Wow. So okay, let's regroup. Let's think about. Okay, so a person coming in for their first session who's just made a suicide attempt in this case. They don't want to hear about reasons for living. In fact, if you if you push reasons for living, I mean, that's an empathic failure. Of what I'm going through. That's your agenda, not mine. I'm focused on the dying. Yeah. So if you dial into my to that with me and you can tolerate it and be there with me, that's really helpful. And then as we start to make a little therapy traction on your drivers, we see. Oh, absolutely. Take off. And and in the meta analysis of the nine cams trials that came out in 2021, decreasing hope and increasing hope of decreasing hopelessness and increasing hope was the single biggest effect size of camps. And I just love that finding because I mean, one drop ideation and some distress and attempt behaviors and the things that we've been able to do. But I love that this is a treatment for hope. Because that is what makes the world go round. And for people who are suicidal, it is not where they are. It's not where they are. It's not what they it's not what they can muster. But with just a little bit of progress, they can get on the hope train and they can ride that train out of out of the hell they're in. So a great subtitle for the book you know manage of managing suicidal risk a treatment for hope like can. Yeah no. You know in reading through as it comes through, it feels. I as someone who I've heard of the Kims, but I can't say that it was something I was very familiar with before, you know, going to the third edition here. And yeah, like it know, it sparked that interest. It was like, wow. Like, okay, what a different approach. Because it was, there was fear. There was a lot of insecurity there and working to say, okay, we can have a greater sense of confidence as clinicians and we can inspire a greater sense of of hope for our clients And what clinician doesn't like inspiring hope? You know, one of my greatest compliments is when people say, oh, you've never done anything new. That's just good social work. This is good psychology. And I don't dispute that. You know, I think I think psychotherapists and counselors who get it love this model because it just feels intuitive and feels like, you know, that something that they've been doing ever since they were in the field. And I love those people. And they and they, you know, they they can readily embrace it. But for a lot of people, this is such a scary topic. For a lot of clinicians, it's such a scary topic and they just rather get rid of the patient. And yet if we can kind of like hit the pause button and sort of look at that and sort of peel away what's behind the fear, you know, mind you, if the fears are on my ability, the self is your is your armor for litigation because documentation is what makes tort litigation from malpractise go round. So you are documenting extensively. The work in session with the patient. The patient's got a copy of their CSF. You're doing it during the sessions. So it's kind of all done as part of the treatment and there's a little bit additional documentation after the session that takes two or 3 minutes, and that's your bulletproof, and you're bulletproof from Malpractise more or less because you didn't fail to assess, you didn't not treat this issue, and you can drop the ball because we're tracking the risk until it resolves. I think the other the other piece of it, we've kind of maybe said this, but it's I also think this model gives people permission. It meaning clinicians permission to talk about it instead of solving it and to be comfortable in, you know, talking about the drivers. And, you know, I thought it was interesting when you said that it jumping to trying to get people to focus on why they want to live, how that's actually therapeutically counterintuitive. We really need to actually talk about the fact that they want to die and what those drivers are. Yeah, I think that's that's a great point of CAMHS is that almost I almost feel like it gives permission for us to stay there with the patient for a minute and to listen and then they feel understood and we don't have to try to solve it immediately. That's not the that's not the goal. It's it's that connection. And then we say this, you know, doing this podcast for a while, I always thought it keeps coming back to connection. You know, it's like it was everything we talk about. It comes back to, you know, and yeah, what, what, what a great fundamental but even in this case how important it is to to just be with that person and and it's okay to be in a bad place with that person initially. That's it's hard to tolerate until you discover that you can do it right. And then you wonder why you never did it before. Because it's an exposure. Yeah. Yeah, it is. And so that that is Paul's point earlier. It is a bit of a double entendre. You know, when we talk about this, our risk is it's managing it certainly manage the risk in the patient but managing the anxiety in the clinician as well. Yeah. So David, Dave, I wish we could, we could spend all all day talking about this. And I appreciate you taking time to just give us kind of a kind of a starting point, but just in, you know, making sure we're keeping with your time as well. We like to kind of wrap up our our episodes and kind of just get some tidbits and some takeaways for our guests. And so we usually end with kind of three questions. And the one and I think maybe I even know the answer to this, I'm going to ask it anyhow. What keeps you psyched to do what you do to keep you motivated to do this line of work? Well, I always tell my students around the life saving business, you know, and it's a pretty cool thing. And the suicide prevention lab accounts like you or I am, you know that the students are on fire for this stuff and it really feels like we're doing something special. And was and I've even kind of expanded my thinking about this or evolved it where I'm less focused on preventing suicides. I'll always be about that. I'm much more focused on the suffering. I'm much more focused on this massive population of people that have these serious thoughts, serious thoughts of suicide within 30 days of the SAMHSA survey And those are the people that we can best treat with this intervention. And then, you know, I think the other thing that keeps me going is that in studying suicide, it may sound crazy, but I know so much about life. And so I'm teaching a new undergraduate course called The Psychology of Life next year, and it's a lot of it. The first four classes are about suicide because, you know, when you study why people want to give up on life, you learn a lot about what makes life worth living. And when you have a treatment that helps save lives, you learn a lot about what that what that bridge to the other side looks like. And so I really am fascinated with with this topic and I'm proud of book and me to write about the psychology of life. Awesome. We also like to kind of get one piece of media, whether it's a book, TV show or movie, if there's one that you can recommend listeners to to check out other than your own, what would it be? I am really keen on a book by Matt Haig called The Midnight Library. And it's a it's a great read. He's amazing writer. He's a person almost took his life in Spain. He was literally at a cliff about to jump and and walked back and recovered. And the library is about possible lives. It's got a suicide theme in the front end. So that's a that's a hook for me. But it's a it's the midnight library is all the possible lives that we live. Every book is a different life we could live. And I find good psychotherapy is perspective cultivation. The Minute Library is a book that really gets you thinking about the possibilities of life and that if you don't like your life, you could live a different life. Is that just like snapping your fingers? But it does make you think and it does make you reconsider your choices and how to live intentionally. And that's a big thing that is important to me. I've never read it, but at least the site sounds great. Yeah, that's. That's great. I got another one, though. Yeah. Yeah. There's another book I just finished called Desperate Remedies A Psychiatrist Search for a Cure. It's a fascinating, fascinating read about the history of mental health care in psychiatry and how how wealthy families who had the mentally ill loved ones would pay anything for a cure. And so it it just walks you through the sort of history of the asylum movement and psychoanalysis and the icepick lobotomies. And I'm. I'm just fascinated with that history and. Yeah. And just think that it's very, I think it's very telling to where we are today and very much with regard to what I think about in terms of hospitals and so forth, that contemporary sense. Awesome. Last last question we like to ask if you can give kind of new clinicians or those listening kind of maybe three gems that you've learned in your career. What are those three things? Find a great mentor and a great mentor in graduate school. And then Marshall Lenihan took me under her wing and dragged me in the field of treatment research, but made all the difference for me. It sounds corny, but I would seek the truth. Yeah. When I was a psych tech were an inpatient unit. I had people sign no harm contracts. And I thought, this is stupid. But I did it anyway. Right. And all these years later, I get to criticize it and offer something better. Hmm. So I was, you know, just honesty is in CAMHS because it's a big part of being a good psychotherapist. I had a I had a professor. This very famous lady. She was elderly and in the seminars like, oh, you young people. You just don't appreciate that honesty is one of the most important things in psychotherapy. And we're like frantically writing down, honestly is important psychotherapy. Now, all these years later, she was right. Honesty is really huge. I guess the third thing would be. You know, really seek out work, love and play. And to try to live intentionally. You know, to me, that that's what I've learned from saying suicide is is is to value my relationships, the importance of my work and what that does for me. And then the importance of being able to play well and to pursue intention, to pursue an intentional life to me is a life worth living. And I think that is a very powerful rap. That's a that's a great one. That's a great what? Dave, we can't thank you enough for sharing your wisdom and, you know, learning about cams in the brief time. And I'm excited to see the third edition of your book. You know, I, I will say personally, I loved having the conversation. And professionally, you've changed the way I do my work. And that's always a wonderful thing. So thank you so much for joining us today. Paul Thank you so much for having me. I've really enjoyed talking to the same. Absolutely. Once again, you know, certainly I'm huge. Thank you, Dave, for joining us on today's episode. And you know, for our listeners interested in learning more, where can they follow you or, you know, just kind of keep track of what you're working on? You know, any area that you can point listeners to. Yeah, the lab website, a Catholic use of you. If you go to the psychology Department of Catholic University of America in D.C., there's a link to me, a link to my lab. And you can kind of see a bit about what we do with our projects, the students and so forth. There is a company called Cam's Care, which is a training company that we found out almost ten years ago next month and it's cams hyphen care dot com and that is a resource for kids but also for other things in the field. All the webinars that we've recorded are free and downloadable. Lots of free. Good stuff there. And then the third thing I would say is I've been ironically coming full circle. I've become a blogger for Psychology Today. And so I've done two, two blogs, maybe three, I can't remember. And it's a really cool forum. And yeah, you know, I feel like it's a bigger audience and I get to sort of spout off on some of these things. And so you can look for me on the Psychology Today website or look track those blog stuff you want to wonderful personally be doing that myself so and if you're interested in hearing more and staying up to date with what's going on for site to practice, visit our website at WW W dot site to practice dot com or follow us on all major social media by searching site to practice. We'll be back in two weeks, but until then, be well and stay psyched.