When I reflect back on my formative days in graduate school and early-on in my career, I was mentored by psychologists who were all board certified, including most of my professors (some of whom later became clinical practice partners for many years). In my early days of training in clinical psychology, seeking board certification was basically a given. I accordingly pursued and received my ABPP in Clinical Psychology when I became eligible. In my mind, being board certified in my specialty has proven to be central to my professional identity as a clinical psychologist. Moreover, most of my key mentors, colleagues, and collaborators have also been board certified. I believe this identity has helped me form a foundation that has enabled me to create a novel suicide-focused clinical intervention that is increasingly used in the United States and abroad. The evolution of the “Collaborative Assessment and Management of Suicidality” (more simply known as CAMS) has been a steady progression from simple clinical observations to a proven suicide-focused treatment supported by dozens of publications including eleven open clinical trials, seven randomized controlled trials (RCTs), and two meta-analyses.
The Seeds of New Ideas
I had my first mental health clinical experience in 1982 working as a Psych-Tech on a locked inpatient psychiatric unit. As a staff member, I met with my assigned patients, participated in various group sessions, and dutifully wrote my SOAP notes every shift. As part of my job, I often responded to “code red” emergencies (i.e., involving seclusion and restraint) of patients who were behaviorally out of control (and oftentimes acutely suicidal). As a young graduate student, I knew nothing about suicide, a topic that would soon become my professional passion for the next 40+ years. When I reflect on this inpatient experience, I had early insights that would later become central to my career as a treatment researcher. For example, I knew—even then—that “no-harm contracts” (i.e., coercively having a patient commit to not to take their life) made utterly no sense. Moreover, I observed that treating depression with anti-depressant medication or psychosis with anti-psychotics was often helpful symptomatically, but did not have much impact on patient’s suicidal thoughts, feelings, and behaviors. I often heard patients voice resentment at being reduced to a diagnosis. I distinctly remember a patient saying to me that he just wanted people to understand what it was like to be him. These nascent clinical experiences were formative as was the influence of my major professor—Alan Berman, PhD, ABPP—who opened the world of suicidology to me and introduced me to the founders of the field.
Directly after my clinical internship at a VA Medical Center, I was hired as a staff psychologist in the Catholic University Counseling Center in 1987. The director was a suicidologist who knew about my thesis and dissertation research on psychological autopsies and suicide. Within my first weeks on the job he assigned me the task of developing a new clinical approach for effectively assessing suicidal risk and tracking the risk of student-clients who were suicidal. With the first of five iterations of the “Suicide Status Form” (SSF) a line of clinical research was born. This work ultimately resulted in the creation of the CAMS and those early years when I talked to dozens of inpatient clients who were suicidal planted the seeds of key ideas that inform CAMS.
The Sprouting of a New Approach
I count myself lucky to have been of a generation where I was influenced by some of the legends of my field. But the one person who made all the difference for me was Marsha Linehan, PhD, ABPP—the famed creator of Dialectical Behavior Therapy (DBT). For reasons I may never fully understand, Marsha decided to take me under wing and mentor me into the world of grant writing, clinical treatment research, and the determined pursuit of RCTs to further explore and validate the key ideas embodied within the CAMS approach to suicidal risk. With Marsha’s guidance and many years of exploration and clinical trial research the central tenets of the CAMS framework began to emerge and evolve. These include: (1) seeing suicide as a proper focus of clinical treatment (vs. focusing on a mental disorder), (2) working to keep a person who is suicidal out of an inpatient setting (if at all possible), (3) the superiority of various forms of stabilization planning over no-harm contracting or commitments to safety, (4) the critical importance of empathy for suicidal thoughts and feelings and the need for collaboration with the patient to realize successful care, and (5) focusing therapy on identifying, targeting, and treating patient-defined problems (i.e., suicidal “drivers” in CAMS parlance) that make suicide compelling to the patient. Marsha was not only generous towards me, but in her inimitable way, she decided that the field needed to be changed and to this end she convened a series of meetings in Seattle in the early 2000’s to explore grant writing, clinical trial research methodology, and the importance of RCTs. Early and mid-level investigators were invited to attend and bring three students. It turns out that most of the major figures in the field today attended these early meetings in Seattle – her ambitious goal of transforming the field is now becoming a reality.
For me, the combination of great mentors and amazing colleagues was the formula to finally flourish as a clinical trial researcher. After ten years of writing unfunded grant proposals for clinical trials, I finally started to receive RCT funding. With a number of early journal articles supporting the clinical utility of the SSF (e.g., Jobes et al., 1997) and with one published non-randomized clinical trial of CAMS conducted in two U.S. Air Force clinics in Colorado (Jobes et al., 2005), I felt compelled to write a book about the emerging CAMS approach. In 2004 I was elated to land a contract to write a book with Guilford Press entitled Managing Suicidal Risk: A Collaborative Approach in which I made the case for CAMS and the key ideas embodied in the approach (Jobes, 2016). The book heavily emphasized the SSF assessment aspects as I endeavored to convince readers of the essential “pillars” of CAMS—collaboration, empathy, honesty, and suicide-focus. The book also foreshadowed the cavalcade of clinical trials/RCTs that have followed over the past twenty years. Consequently the 2nd edition of the book was published in 2016 featuring support from two published RCTs of CAMS with a clear focus on driver-focused treatment that has become a signature feature of the intervention (Jobes, 2016).
The Harvest: Managing Suicidal Risk
In August 2023, the 3rd and final edition of Managing Suicidal Risk: A Collaborative Approach was published (Jobes, 2023). This 3rd edition is special to me and feels like a fitting culmination of a 40+ year evolving journey. It features the seven published RCTs and also focuses on the back-end of CAMS—the resolution of suicide risk which emphasizes effectively managing suicidal thoughts/feelings and realizing behavioral stability. There is also attention paid to steps beyond CAMS—the promise of pursuing a life worth living with purpose and meaning. Having recently turned 65, I feel like I am personally entering into the autumn of life. I plan to work several more years to see through five existing CAMS RCTs to coast into retirement. But upon reflection, I feel blessed to have had the opportunity to develop, nurture, and evolve CAMS into the full-blown and proven clinical intervention that it is today for reliably reducing suicidal suffering. What I have come to see and appreciate over the decades is that when a clinical dyad finds a way for the patient to manage suicidality and achieve behavioral stability, a most profound clinical achievement has been realized. In a meta-analysis of nine CAMS trials, the biggest effect in support of CAMS was for increasing hope while also decreasing hopelessness (Swift et al., 2021). For me, this is one of the most gratifying of all research findings across thirty years of CAMS clinical trial research, because when the flame of hope is lit really anything is possible!
Several years ago I was in the Suicide Prevention Lab watching a fidelity video of an 8th session of CAMS in which an extremely suicidal U.S Army Soldier was now working his way through his final outcome-disposition of CAMS with his provider. This Soldier’s progress within the CAMS framework was nothing less than remarkable. His self-identified suicidal driver of combat-related PTSD was being effectively treated by prolonged exposure and his symptoms had notably remitted. His second suicidal driver was related to losing his kids to his estranged wife. His CAMS clinician had helped the Soldier engage a JAG attorney who successfully negotiated joint custody of his two young children. Another breakthrough was a decision to leave the Army, and his CAMS clinician had helped connect him to VA services including vocational rehab. The Soldier was thus clinically stable and managing occasional suicidal thoughts and feelings quite well, thereby meeting criteria for resolution of CAMS. Imagine my shock when at the end of this final session, the grateful Soldier turned directly to the camera mounted on the clinician’s computer, and said “…thanks you guys who are watching in DC, this treatment really helped me…for the first time in my life, I feel like someone understood what it was like to be me!”
References
Jobes, D. A. (2000). Collaborating to prevent suicide: A clinical-research perspective. Suicide and Life-Threatening Behavior, 30, 8-17.
Jobes, D. A. (2006). Managing Suicidal Risk: A collaborative approach. The Guilford Press.
Jobes, D. A. (2016). Managing suicidal risk: A collaborative approach, 2nd edition. The Guilford Press.
Jobes, D. A. (2023). Managing suicidal risk: A collaborative approach, 3rd edition. The Guilford Press.
Jobes, D. A., Jacoby, A. M., Cimbolic, P., & Hustead, L. A. T. (1997). The assessment and treatment of suicidal clients in a university counseling center. Journal of Counseling Psychology, 44, 368-377. https://psycnet.apa.org/doi/10.1037/0022-0167.44.4.368.
Jobes, D. A., Wong, S. A., Conrad, A., Drozd, J. F., & Neal-Walden, T. (2005). The Collaborative assessment and management of suicidality vs. treatment as usual: A retrospective study with suicidal outpatients. Suicide and Life-Threatening Behavior, 35, 483-497. https://doi.org/10.1521/suli.2005.35.5.483.
Swift, J. K., Trusty, W. T., & Penix, E. A. (2021). The effectiveness of the collaborative assessment and management of suicidality (CAMS) compared to alternative treatment conditions: A meta-analysis. Suicide and Life-Threatening Behavior, 51(5), 882-896 https://doi.org/10.1111/sltb.12765.
David A. Jobes, PhD, ABPP
Board Certified in Clinical Psychology
Correspondence: jobes@cua.edu