Working with suicidal clients using the Collaborative Assessment and Management of Suicidality (CAMS).

The Collaborative Assessment and Management of Suicidality (CAMS) was developed to modify clinician behaviors in how they initially identify, engage, assess, conceptualize, treatment plan, and manage suicidal outpatients. This approach integrates a range of theoretical orientations into a structured clinical format emphasizing the importance of the counselor and client working together to elucidate and understand the "functional" role of suicidal thoughts and behaviors from the client's perspective. Based on clinical research in various outpatient settings, CAMS provides mental health counselors with a novel clinical approach that is tailored to a suicidal client's idiosyncratic needs thereby insuring the effective clinical assessment, treatment, and tracking of high risk suicidal clients.

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It has been eight years since the United States Surgeon General David Satcher, sounded the alarm about the profound impact of suicide in his Call To Action to Prevent Suicide (U.S. Public Health Service, 1999) imploring the public health, mental health, and medical communities to seriously address the issue of suicide. Since this time there have been various efforts towards developing community-based prevention strategies but remarkably few efforts have specifically focused on the development of effective clinical assessments and treatments of suicidal individuals. Despite the increased awareness of suicide as a major public health problem, gaps remain in training programs for health professionals who often come into contact with suicidal patients in need of these specialized assessment techniques and treatment approaches. Studies indicate that many health professionals are neither adequately trained to provide proper assessment, treatment, and management of suicidal patients, nor do they know how to refer clients properly for specialized assessment and treatment (U.S. Public Health Service, 2001; Bongar, 1991). For many years, suicidality has been the most commonly encountered clinical emergency for mental health professionals (Schein, 1976) and mental health counselors continue to be critically positioned on the front lines for clinically assessing, referring, and treating suicidal individuals (Barrio, 2007).

While a number of suicide risk instruments exist, survey research indicates that the majority of mental health counselors prefer to rely on a clinical interview to assess suicide risk (King, Kovan, London, & Bongar, 1999). In terms of clinical treatments for suicidal risk, there has been a remarkably limited empirical literature for treating suicidal states. Indeed, most of the extant literature over the past decades has been theory-based or anecdotal with limited empirical support (Jobes, 1995; 2000). In more recent years, however, a growing number of researchers have developed and empirically investigated more suicide-specific clinical approaches (e.g., Brown et al., 2005; Henriques, Beck, & Brown, 2003; Linehan, 1993; Rudd, Joiner, Jobes, & King, 1999; Rudd, Joiner, & Rajab, 2001). As part of this trend, the Collaborative Assessment and Management of Suicidality (CAMS) was developed to modify clinician behaviors in how they initially identify, engage, assess, conceptualize, treatment plan, and manage suicidal outpatients. In our view, this novel clinical approach can be used in a variety of mental health settings, including outpatient clinics, community mental health centers, private practice, employee assistance programs, prisons/jails, and even inpatient units (Jobes, 2006).

At the heart of the CAMS approach is an emphasis on a strong therapeutic alliance where counselor and client work closely together to develop a shared understanding of the client's suicidal phenomenology. An interactive assessment process is used to build a clinical partnership; risk assessment information gleaned from this process is then used to directly shape a suicide-specific treatment plan. Unlike traditional "Kraepelinian" approaches that emphasize treating a diagnosed psychiatric illness with the assumption that treating the illness will reduce the symptom of suicidality, CAMS is designed to specifically target suicidal ideation and behavior as the central clinical problem, independent of diagnosis. Through collaborative assessment and deconstruction of the patient's suicidality, key problems and goals naturally emerge. Collaborative treatment planning that follows thus creates a problem-focused approach that is designed to reconstruct more viable ways of coping and living. CAMS is designed to be flexible and facilitate therapeutic work, independent of theoretical orientation or clinical techniques. The approach therefore does not usurp clinical judgment or professional autonomy--it provides helpful front-end guidance on how to handle suicidality quickly and directly without getting into an adversarial power struggles (Ellis, 2004; Jobes, 2000). CAMS, therefore, fosters collaborative teamwork, launching a superior treatment trajectory and outcome (Jobes, Wong, Conrad, Drozd, & Nell-Walden, 2005).

THE CAMS APPROACH: THEORY AND PRACTIE

As noted, CAMS is designed to be a uniquely flexible and adaptive clinical framework that can be used eclectically. The approach embraces a range of theoretical approaches and employs certain practice procedures helping to create structure and guidance--a clinical roadmap--for effective care of suicidal clients.

Theoretical Aspects of CAMS

The CAMS approach to suicidality integrates a range of theoretical orientations (including psychodynamic, cognitive, behavioral, humanistic, existential, and interpersonal notions) into a structured clinical format emphasizing the importance of the counselor and client working together to elucidate and understand the "functional" role of suicidal thoughts and behaviors in the patient's phenomenological world (Jobes & Drozd, 2004). This approach embraces some overarching assumptions about suicidal states. For example, within CAMS there is a basic belief that suicidal thoughts and behaviors represent a fundamental effort to cope or problem-solve, in pursuit of meeting legitimate needs (e.g., needs for control, power, communication of pain, or an end to suffering). From this perspective, a CAMS counselor approaches suicidality in an empathic, matter-of-fact, and non-judgmental fashion. Ironically, the counselor's capacity to understand and appreciate the viability and attraction of suicide as a means of coping provides the essential ingredient for forming a strong therapeutic alliance where more adaptive methods of coping can be evaluated, explored, and tested. Philosophically speaking, CAMS emphasizes an intentional move away from the directive "counselor as expert" approach that can lead to adversarial power struggles about hospitalization and the routine and unfortunate use of coercive "safety contracts" (Jobes, 2000; 2006).

Overview of Practice Procedures

Generally speaking, the CAMS method is initiated when a client acknowledges current suicidal ideation, either through a self-report instrument or during a clinical interview. Clinical assessment pertaining to the client's suicidal phenomenology is accomplished by collaboratively completing an assessment tool called the Suicide Status Form (SSF). The SSF uses both quantitative and qualitative responses to assess key variables of suicidal risk (refer to CAMS case example that appears later). Built on the theoretical work of Shneidman (1993), Beck et al (1979), Baumeister (1990), Linehan et al (1983), and Jobes (1995), the SSF uses Likert and qualitative open-ended items related to the client's psychological pain, stress, agitation, hopelessness, self-hate, and overall suicide risk (Jobes, 2006). Use of the SSF is introduced as a collaborative endeavor, wherein the counselor asks for permission to literally take a seat next to the client to more thoroughly assess, understand, and appreciate the client's pain and suffering that leads to suicide as a means of coping. The dyad then works together to rate, describe, and rank order the client's responses to the SSF. Throughout the assessment process, the client's perspective is treated as the assessment gold standard. Completion of the SSF clarifies the nature of the client's suicidal pain and suffering and sets the stage for a treatment planning process where the client and counselor co-author an outpatient treatment plan. Within CAMS, suicidal clients are administratively placed on "Suicide Status" and are subsequently reassessed at every subsequent clinical contact where suicide-specific treatment plans are routinely updated until clinical "resolution" is achieved (i.e., three consecutive sessions of no suicidal thoughts, feelings, and behaviors--see Jobes et al., 1997).

STEP-BY-STEP PROCESS OF CAMS

Elsewhere we have described the process of CAMS involving five major procedural steps. What follows is a more detailed discussion of this engagement that shapes the assessment/treatment process (Jobes & Drozd, 2004).

Step 1: Early Identification of Risk

As just noted, typically the entry point for a new or ongoing client to be engaged in CAMS occurs when a client self reports current suicidal ideation. While a client's verbal self-report of ideation is an acceptable entry point to CAMS, the preferred and recommended approach is for CAMS to be triggered by a psychometrically sound symptom-oriented assessment tool. For example, CAMS was successfully used in outpatient military treatment settings following the confirmation of a suicide assessment item taken from the Outcome Questionnaire 45.2 (Lambert et al., 1996), which was routinely administered before initial intakes and at each subsequent clinical contact (Drozd, Jobes, & Luoma, 2000; Jobes et al., 2005).

The triggering suicide ideation question of the OQ-45.2 (item # 8) reads, "I have thoughts of ending my life," which can be answered with a 0 (never), 1 (rarely), 2 (sometimes), 3 (frequently), or 4 (always). The response to this question is thus used to alert the clinician about the client's current suicidal ideation before initial face-to-face contact is made. In a sense, this approach gives the clinician a type of early warning signal to detect and prepare to address the client's suicidal risk near the start of the session. In our Air Force clinic study, a client was operationally considered suicidal if at intake or any point in treatment they marked a 2, 3, or 4 on item #8 of the OQ-45.2 (Jobes et al., 2005).

Besides the OQ45, there are a variety of other similar symptom-oriented tools that can be used to trigger the CAMS approach. For example, the Brief Symptom Inventory (BSI) or the Behavioral Health Measure (BHM) are additional examples of similar scales that have suicide ideation items like the OQ-45 (see Jobes, 2006 for a more thorough discussion of these symptom-based tools). Some clinicians argue that routine use of such tools is aversive or too demanding on the client (refer to Jobes, Eyman, & Yufit, 1995). We suggest the regular use of brief symptom assessments collected at every clinical contact is analogous to medical personnel routinely taking a patient's vital signs to monitor overall physiological functioning and health. Early identification of suicidality is crucial to successful use of CAMS, optimizing the full benefits of collaborative assessment and treatment planning. Given the import of the issue--and the inherent tendency of some clinicians to avoid the topic--suicidal risk is not something that should be identified in the last 10 minutes of a counseling session. Indeed, using the CAMS approach, current suicidal thoughts are identified within the first 10 minutes of a session and are addressed as forthrightly as possible.

Step 2: Collaborative Assessment Using the SSF

The CAMS approach is thus triggered by the presence of current suicidal ideation as revealed through an intake form or verbal query. The collaborative in-depth assessment of suicidal risk more specifically begins by asking the patient for permission to literally take a seat next to them in order to complete the Suicide Status Form together. In this fashion, a clipboard is handed back and forth between the client and counselor during the assessment; literally and figuratively the dyad are endeavoring to work off the same (assessment) page. The first page of the SSF involves completion of various Likert scales, qualitative assessments, and rankings. These assessment constructs provide plenty of opportunity for discussion and joint effort. The SSF assessment provides an important framework for understanding the idiosyncratic nature of the client's suicidality so that both parties can intimately appreciate the client's suicidal pain and suffering. Completion of page 1 (i.e., Section A) of the SSF typically takes 10-15 minutes. This initial joint assessment activity then leads to the clinician taking back the clipboard and completing the clinical assessment at the top of page 2 (i.e., Section B), which was specifically constructed to assess for the most pernicious risk variables according to recent empirical research (Jobes, 2006).

Step 3: Collaborative Treatment Planning

When sections A and B are complete, the dyad is then in a position to coauthor the "Outpatient Treatment Plan" (Section C). At this juncture of the CAMS-based counseling engagement, both parties have achieved a very thorough understanding about the client's suicidal experience, thereby revealing what must be done to in terms of treatment with the goal of being able to pursue outpatient care. In other words, within CAMS outpatient care is the explicit goal of the counselor. Thus, this approach rejects an automatic assumption that suicidal clients belong in inpatient settings (Jobes, 2000). In this spirit, the first problem to address with the client is their "Self-Harm Potential," in turn the first treatment goal and objective is "Outpatient Safety." By beginning the treatment focus explicitly on desire to pursue outpatient care, the dyad can work to figure out the specific interventions and elements of the "Crisis Response Plan" that must be established in order for appropriate outpatient care to proceed (see Rudd, Joiner, & Rajab, 2001). Subsequent problems, goals and objectives, can then be pursued based on additional assessment data obtained from the SSF. Within the CAMS approach, when the Outpatient Treatment Plan is complete, the client is then operationally understood to be on "Suicide Status"; on-going suicide risk is then monitored and tracked at each subsequent clinical contact using the SSF "Suicide Tracking Form" (see Jobes, 2006).

Step 4: Clinical Tracking of Suicide Status

At each subsequent clinical contact, the client's self-report SSF assessment is quickly completed at the start of each session. At the end of these sessions, the Outpatient Treatment Plan is revisited to either continue, revise, or update as needed depending on new issues that emerge or clinical progress that is made.

Step 5: Clinical Outcomes of Suicide Status

Three consecutive sessions of no suicidal ideation/feelings/behaviors is the operational definition that a Suicide Status CAMS case is resolved. SSF Suicide Tracking Outcome Forms are thus completed, the patient is no longer on Suicide Status, and use of normal clinical records is resumed (Jobes, 2006). There are of course other possible clinical outcomes (e.g., referral, unilateral drop out from care, or perhaps hospitalization). The SSF outcome forms can be similarly used for these alternative outcomes to insure a complete accounting of the care within the medical record.

SSF/CAMS EMPIRICAL SUPPORT

To date, a series of studies have confirmed the use of the SSF and the promise of CAMS as viable clinical approach (refer to Jobes, 2006 for a complete review of this research literature). There is strong empirical support for the inherent validity and reliability of the SSF as an assessment tool (Jobes et al., 1997; Conrad, 2007). Other studies have demonstrated the value of the CAMS qualitative assessments (e.g., Jobes & Mann, 1999; Jobes et al., 2004). In terms of the CAMS (and this particular use of the SSF), there are additional supportive data. For instance, in our previously mentioned use of CAMS in two outpatient Air Force clinics, we found that CAMS clients resolved their suicidal thoughts significantly more quickly (about four to six sessions sooner) than treatment as usual clients. In addition, CAMS clients had significantly fewer (i.e., half as many) non-mental health medical visits (ER and primary visits) than treatment as usual clients (Jobes et al., 2005). Similarly, reductions in suicidal thoughts have been consistently seen in university counseling center settings were CAMS has been used (Jobes et al., 2007). Of course these encouraging preliminary findings need further replication, particularly using a prospective randomized clinical trial (RCT) design, which we are currently pursuing to definitively demonstrate that using CAMS causes reductions in suicidal ideation/behaviors and non-mental health medical appointments.

CAMS PROBLEM-SOLVING TREATMENT (CAMS-PST)

As we venture into studying the use of CAMS in prospective randomized clinical trials, it has been necessary to move from the existing eclectic treatment framework used to date in our correlational studies, in order to develop a version of CAMS that can be considered a freestanding discrete treatment of suicidal risk. To this end, we have recently developed a short-term treatment version of CAMS dubbed the "Collaborative Assessment and Management of Suicidality-Problem Solving Treatment" (Jobes, 2006). At this juncture, CAMS-PST has been conceived as a suicide-specific, problem-focused, intensive outpatient treatment that is administered across 12 sessions. This new therapy is shaped by five critical components of collaborative care that should routinely occur in each session and across the course of treatment. These components include the following:

1. Collaborative assessment of suicidal risk using the SSF.

2. Collaborative suicide-specific treatment planning.

3. Collaborative deconstruction of "suicidogenic" problems.

4. Collaborative problem-solving/problem-focused interventions targeting those problems that directly contribute to suicidal risk.

5. Collaborative development of reasons for living and protective factors (e.g., a significantly improved capacity think about the future and plan more effectively).

Suicidal ideation is thus identified and tracked through weekly administrations of the SSF. In CAMS-PST, suicide specific treatment typically focuses on issues that our previous research (Jobes et al., 2004) has shown are central to most suicidal states (e.g., relational problems, vocational problems, self-oriented problems, and pain/suffering.). Like the eclectic use of CAMS, a central treatment goal within CAMS-PST is to establish a viable outpatient treatment plan that can keep the patient out of the hospital. This goal is largely achieved by careful development of the previously noted Crisis Response Plan (instead of traditional "safety contracts"--refer to Rudd et al., 2001). Within CAMS-PST care, pre-existing "suicidal coping" is systematically eliminated by teaching empirically validated problem-solving, problem-focused, grounding, and self-soothing techniques (Brown et al., 2005; Kehrer & Linehan, 1996; Najavits, 2002). There is a central focus on increasing psychological pain tolerance, creating alternative and better ways of coping, and ultimately making a life worth living.

This new treatment intervention is currently being administered as part of two new randomized clinical trials. The first RCT is an intensive outpatient study being conducted at the Denver VA Medical Center. A similar RCT is currently under development at Harbor View Hospital in Seattle for recently discharged Emergency Room suicidal patients. In both these settings, we are attempting to study whether CAMS-PST--in comparison to treatment as usual--actually proves in fact to be an effective/viable, cost-effective, outpatient treatment to high-risk suicidal outpatients.

CASE EXAMPLE: A SUICIDAL VETERAN

"Hank" is a 24-year old Operation Iraqi Freedom (OIF) combat veteran. He joined the Marines soon after the attacks of 9/11 and he served until February 2006. Hank spent a total of almost two years in Iraq in the course of two separate deployments. His duties involved high-level communications. During the time that he was in theater he was exposed to multiple improvised explosive devices (IED's). One such attack ultimately wounded his right leg which led to his medical discharge and disability compensation from the VA.

When asked about traumatic combat-related experiences, Hank recalled seeing many mutilated bodies of Iraqis and witnessed four fellow Marines being shot and killed. Hank grew up in Colorado Springs in a military friendly environment. After 9/11 he felt compelled to do something for his country, he thus dropped out of community college and joined the Marine Corps. Since returning from Iraq, Hank has experienced significant break-though symptoms of PTSD including startle response, flashbacks, hyper vigilance, nightmares, and social avoidance. At the time of intake, Hank reported feeling hopeless about the world and his future and he endorsed persistent suicidal ideation and had recently held a gun to his head. Hank had not been using alcohol or drugs, although in the past this had been a means of coping and he worried about falling back into those "old bad habits." He spends most of his time sitting in his apartment, watching TV, and thinking about his experiences in Iraq. Hank is relatively isolated and has limited contact with friends; he does regularly speak to his parents and siblings (who worry about him).

Course of CAMS Care

As shown in Figure 1, the initial treatment session consisted of the collaborative assessment of the suicidal ideation and risk factors (Sections A and B of the SSF) and the completion of a suicide-specific treatment plan, including the creation of a Crisis Response Plan (Section C). As described earlier, Hank was administered the SSF in order to better understand his unique suicidal pain and suffering so the factors pushing him towards suicidal coping could be directly targeted in treatment. As shown in Figure 1, Hank reported high ratings across the five constructs listed in the upper portion of the SSF. He ranked psychological pain as the most distressing variable, followed by hopelessness, stress, agitation, and self-hate. In terms of qualitative assessment, his written responses reveal various-PTSD related issues and a desire to have a normal life (e.g., finding a girlfriend and getting a job). These qualitative written responses were crucial for the clinician to fully understand Hank's problems that lead to his considerations of suicide. With this SSF-informed understanding, there was valuable information that could be used to collaboratively develop a suicide-specific treatment plan that could appropriately keep him out of the hospital. As noted under the Crisis Response Plan, the removal of his gun, the use of a "Crisis Card and interventions designed to increase his social support were central to getting Hank through this difficult period of acute (suicidal) distress (see Jobes, 2006). In this case, the "Crisis Card" was simply a business card with various cognitive behavioral interventions written on the back that Hank can use if a crisis situation arises (Jobes, 2006). Other aspects of the treatment included interventions designed to treat his symptoms of PTSD and get him back to work.

[FIGURE 1 OMITTED]

In the early phases of his care there was a great deal of emphasis on learning to problem solve more effectively (refer to Nezu & D'Zurilla, 1989). A critical turning point was Hank connecting to a fellow Marine who he had known in Iraq. Critically, this friend convinced Hank to join him in a PTSD group at the VA hospital. Through this connection he began to slowly build a social network. With a great deal of encouragement he also enrolled in a vocational rehabilitation program at the hospital. Hank was taught various "grounding" techniques to help deal with PTSD symptoms and also effectively used his Crisis Card when he found himself in trouble (Jobes, 2006; Najavits, 2002). In the course of testing these new interventions, Hank began to develop better coping skills that were initially aimed at managing suicide-related impulses but he later learned that these skills generalized to non-suicide related coping. These various coping skills included an improved capacity to self-sooth, various delaying tactics (to not behave impulsively), redirection techniques, and various means of contacting supportive others (including his counselor in an acutely emergent situation).

Thus, the focus of sessions 2-4 heavily emphasized the development of problem-solving skills designed to specifically target different issues that gave rise to his suicidal thoughts. As his overall global functioning began to improve, Hank began to report that he was more hopeful and that he had noticed increased reasons for wanting to live. Although Hank's SSF tracking forms continued to indicate relatively frequent suicidal thoughts, he insisted that such thoughts were passing and that he did not dwell on them for very long. Through the use of his Crisis Card between sessions, he became aware that his suicide ideation was intensified when he was home alone in the daytime. A behavioral plan was constructed to maximize his time outside his apartment so he could be more involved in the community. His initial reluctance to seeing a vocational rehabilitation counselor ultimately resolved and this particular intervention gave him a significant lift as he began to realize that he may be able to return to work. At the end of his fourth session, Hank reported that the new problem-solving approaches he was learning were helping him to make better decisions overall, which greatly reduced his typically intense reaction to stressors. In turn, he observed, that he was now taking time to consider alternative decisions before acting.

Sessions 5-8 were marked by significant declines in severity ratings on the SSF tracking sheets. During session 6, both counselor and client agreed that SSF treatment plan needed to be significantly updated to better match his emerging goals. While progress was self-evident, Hank nevertheless noted a new assortment of stressors that were causing anxiety and affecting his fragile self-confidence therein. He noted considerable frustration over several employers' concerns with hiring someone with mental health issues--one employer said he could not have a returning vet "going postal."

Following the CAMS Suicide Status procedures, the counselor used the regular assessments of suicidal pain and suffering to further highlight the necessity for the client to continue working hard on his goals; although his suicide ideation was beginning to remit, it could return quickly if his recovery became stagnant or they lost momentum. This conversation led to the client's understanding that becoming suicidal is like a chain-reaction, set off by multiple stressors that intensify one's emotions and limit the ability to problem solve effectively.

By session 9, Hank was no longer reporting any suicidal thoughts and was showing great strides towards a full recovery. He had successfully landed a job with a communications business as a part-time employee and was actively engaged in several veterans-related groups. He had begun dating a woman (for the first time since high school) that he met through his church. The new girlfriend was aware of Hank's mental health concerns and was completely supportive of efforts to seek help. Sessions 11-12 were focused on understanding warning signs for future possible episodes of suicidal ideation and additional healthy ways to cope with stressors that inevitably occur in life. The client stated that he would continue to make a weekly list of reasons for living and would also consider alternatives before making rash decisions when he was feeling emotional. An extended time-line was constructed in session 11 to list the behaviors necessary to achieve his long-term goal of becoming financially independent so that he was no longer reliant on his VA disability compensation and support from his parents Ultimately, Hank requested to "check in" with his counselor every few months. As a born-again Christian, Hank was increasingly inclined to "turn to Jesus" as his primary means of support and healing. After CAMS tracking had resolved, Hank sent his counselor a greeting card of thanks with the note: "Thanks for saving my life!"

CAMS IMPLEMENTED IN ADDITIONAL TREATMENT SETTINGS

As described by Jobes (2006), the SSF (and CAMS administrations of the SSF) have been used extensively in a variety of settings throughout the United States and Europe. To date, CAMS has been used primarily in university counseling center settings (Jobes et al., 2007) and general outpatient treatment clinics (Jobes et al., 2005). However, other adaptations of SSF/CAMS have been applied to hotline/crisis centers, emergency departments, and employee assistance programs (Jobes, 2006).

In terms of new uses of CAMS, we would like to briefly discuss two relatively new applications of CAMS in community mental health settings and on inpatient psychiatric units. Work in these settings represents a new and exciting next phase of CAMS implementation and a new line of clinical research.

Community Mental Health Treatment Centers

Given the success of CAMS in various outpatient clinics, there is every reason to believe that CAMS will be similarly effective in community mental health treatment centers (CMHTC). We are currently in the early phases of working with two large community mental health systems in Northern Virginia. What is striking about these settings is the large volume of relatively sick patients often with remarkably limited resources. These settings are further experiencing increased worries about potential malpractice liability, particularly in a post-Virginia Tech environment (Cornell, 2007; Shuchman, 2007). One of the key virtues of the CAMS approach not yet mentioned is that the extensive assessment and tracking information that is captured by the various SSF forms represents a possible remedy for potential malpractice liability exposure (Wise et al., 2005). Beyond this concern, the eclectic use of CAMS provides a flexible framework in which clinicians of all theoretical stripes can appropriately engage and treat high-risk suicidal patients. One of the unique aspects of community mental health care is the tradition of engaging family systems. We find in the emerging CMHTC CAMS treatment that family members are increasingly becoming engaged as an active adjunct to clinical treatment--helping to insure safe environments, monitoring risky behaviors, and taking some measure of active responsibility for handling crises with the clinician serving as a critical back up player and consultant to the family.

It is often the case that well-designed efficacy-based clinical treatments that work in the research lab, may not always prove to be as effective when applied in real life situations. In contrast to the research lab, there are many extraneous "third variables" that in "real world" settings impact the effectiveness of research-based treatment (e.g., client comorbidity, multiple treatment settings, and clinician availability--refer to Borden & Abbott, 2002; Drake et al., 2001; Pepper, Krishner, & Ryglewics, 1981; Caton, 1981). In our experience, CMHTC clinicians who encounter such difficulties are the norm, rather than the exception. In this regard, because CAMS was developed and used in real-world treatment settings, we believe that it is uniquely capable of handling these complex settings and situations. In other words, there is no need for translating CAMS into a real world environments--CAMS was developed and has always been used "in the trenches" of real-world clinical settings.

Moreover, we believe that the CAMS approach to treating suicide-related behaviors may be a particularly good fit for CMHTC for other reasons. First, inherent within the CAMS model is a specific focus on suicide risk, not various types of mental disorders (Jobes, 2000; 2006). As mentioned above, this approach only serves to strengthen the therapeutic bond between client and clinician, by validating the suicidal experience as an issue that stands independent of a mental disorder. This characteristic lends itself well to treating all clients, as there is a complete absence of exclusionary criteria for determining which persons are eligible to receive CAMS. Therefore, the typical problems that arise in counseling practice where a treatment may only apply to certain problems--but not others--does not hamper the broad-based effectiveness of CAMS (Prochaska, Evers, Prochaska, Van Marter, & Johnson, 2007).

Second, CAMS treatment planning often contains recommendations for additional forms of psychotherapy to deal with specific issues that may underlie the etiology of the suicidal ideation (Jobes & Drozd, 2004; Jobes, 2006). Should a client be in a position where the CAMS approach would be considered a treatment option, suicide ideation has become severe enough that it has now become the priority of issues listed on the client's treatment plan. Yet, given the extent of comorbidity in the generalized psychiatric population (Kessler, Chiu, Demler, Walters, 2005), clients in CMHTC are likely to experience a more rapid recovery rate when symptoms of specific diagnoses, such as PTSD and panic disorder, are addressed in concert with suicidal ideation. Compliance with other treatments is discussed in CAMS sessions, offering a "home base" for clients to discuss all current stressors. This relationship between client and counselor in CAMS can be akin to the case manager/client relationship often seen in CMHTC, wherein the clinician is aware of the full spectrum of client issues and is able to perceive stressors as a gestalt when conceptualizing and managing suicidal risk (Mueser, Bond, Drake, & Resnick, 1998).

This last point is crucial for providing continuity of care for clients across multiple treatment settings and between clinicians. A typical scenario for clients treated through CMHTC is that crises occurring between scheduled sessions will necessitate an emergency treatment session. Given the fact that clinician caseloads in this setting are continually on the rise (Barr, 2000; Okin, 1984), the likelihood that an assigned clinician will be available at a moments notice is often not possible. As mentioned above, the stringent nature of SSF documentation provides clinical supervisors with the most recent index of a client's current suicidal ideation and suicide-specific treatment plan. This documentation also includes a detailed account of the factors involved in the current episode of suicide ideation so that a supervisor or clinician who is "pinch hitting" for the assigned contact person can feel confident and prepared when discussing the client's current crisis.

CAMS, therefore, appears to address many common problems that may ordinarily limit or hamper effectiveness of psychosocial treatment in CMHTC. Additionally, because CAMS does not mandate clinicians to adhere to a specific school of thought, it is likely that a larger number of clinicians would be good candidates for CAMS training (Jobes, 2006).

Inpatient Treatment Centers

The current literature suggests that clients in inpatient treatment centers (ITC) often experience increased rates of suicide during hospitalization (Pompili et al., 2005). Clinical staff working in an ITC are forced to work with exceeding quickness to stabilize severely impaired individuals, many of whom are admitted with elevated levels of suicidality. Thus, it becomes crucial for clinicians to quickly develop rapport and discover the multiple layers of issues that contribute to the client's own suicidal ideation.

Ironically, even though CAMS was originally developed as an intentional alternative to inpatient care, our recent work suggests that a modified version of CAMS may prove to be an excellent fit in an ITC setting because the treatment is driven by collaboration at every step (Jobes, 2006). This collaborative process serves to enhance and expedite the rate at which information is shared in the course of developing a meaningful client/clinician relationship. One major difference from standard CAMS outpatient care is that the emerging inpatient version of CAMS necessarily focuses on discharge. In other words, for CAMS suicidal inpatients, discharge would be contingent on the thoughtful development of a viable Outpatient Treatment Plan that includes a solid Crisis Response Plan. Indeed, we would even advocate a model wherein an inpatient would have to actually demonstrate specific-suicide preventive coping and relapse prevention skills (e.g., refer to Brown et al., 2005) for a discharge to be ordered. Such an approach is markedly different from what is typically done; in most settings, the doctor or nursing staff exacts a verbal or written promise of outpatient safety in order to discharge an inpatient.

In addition to accelerating the therapeutic alliance, CAMS also provides (as noted above) extensive documentation that is necessary in an inpatient setting. Given that ITC are responsible for 24-hour care, it is crucial for clinical staff to have detailed notes regarding suicide specific behaviors to ensure continuity of care across shifts. A study by Wagner, Pollard, Wagner, and Shifren (1994) investigated the University of Texas' medical liability claims spanning from 1978-1991 that dealt directly with adult inpatient psychiatric clients and found that cases involving suicides accounted for the highest percentage of payouts by the university. Additionally, these researchers deemed the medical documentation involved in many of the cases to often be utterly insufficient. In this regard, CAMS SSF documentation exhaustively assesses suicide ideation between individual clinical contacts and provides for a thorough examination of the suicidal ideation rather than the compulsory "safety check." In this way, clinical staff could measure factors related specifically to suicidal ideation, such as agitation and hopelessness (Mann, Waternaux, Hass, & Malone, 1999; Swann et al., 2005; Goldston, Reboussin, & Daniel, 2006), at multiple points throughout the day for high-risk clients.

Finally, in relation to previously noted considerations about discharge, CAMS SSF inpatient documentation could help insure continuity of care during the discharge planning process. Several research studies have found that recently discharged psychiatric clients are at an increased risk for suicide-related behaviors (Ho, 2003; Goldacre, Seagroatt, & Hawton, 1993). It is crucial to recognize the importance of providing continuity of care across treatment settings to ensure that high-risk suicidal individuals do not "slip through the cracks" of an increasingly complicated mental health system. The detailed documentation inherent in the CAMS approach could provide an outpatient clinician with a detailed account of suicide-specific factors discussed while at the ITC, which could then further provide a relatively seamless continuation of the existing suicide-specific treatment plans in the course of follow-up outpatient care.

CONCLUSION

The Collaborative Assessment and Management of Suicidality is one of only a few suicide-specific clinical approaches. As a clinical assessment, treatment, and tracking framework, CAMS does not usurp clinical judgment and it can be used with a range of theoretical treatment orientations. Preliminary research suggests that CAMS is associated with desirable treatment processes and outcomes that arise from strong outpatient alliances that are formed in the course of CAMS care. Current research is attempting to extend the CAMS framework in the development of a new stand-alone treatment that will prove effective in a range of existing and new treatment settings (e.g., community mental health or inpatient units).

In our efforts to work effectively with challenging clinical cases--like suicidal clients--we need to continue to develop new and better approaches to effectively work with such clients, providing them the respect and dignity that all clients deserve. We believe that in cases of suicidal risk, the collaborative engagement of the client in their own assessment and management of their suicidal struggle is crucial to averting tragedy. By discovering and developing alternative and better ways of coping, the mental health counselor can become a part of critical process that systematically eliminates the need for suicidal coping thereby opening the door to the prospect of transforming a seemingly unbearable suicidal life into a viable life that is ultimately worth living.

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David A. Jobes is professor of psychology and co-director of clinical training at The Catholic University of America. Melinda M. Moore and Stephen S. O'Connor are clinical psychology doctoral students at The Catholic University of America. Correspondence regarding this article should be sent to David A. Jobes, Department of Psychology, O'Boyle Hall Room 314, The Catholic University of America, Washington DC, 20064. E-mail: [e-mail].