|
David Jobes, PhD - Guest
Dr.Jobe is a Professor of Psychology, Director of the Suicide Prevention Laboratory, and Associate Director of Clinical Training at The Catholic University of America. Dave is also an Adjunct Professor of Psychiatry, School of Medicine, at Uniformed Services University. He has published six books and numerous peer-reviewed journal articles. Dave is a past President of the American Association of Suicidology (AAS) and he is the recipient of various awards for his scientific work including the 1995 AAS “Shneidman Award” (early career contribution to suicidology), the 2012 AAS “Dublin Award” (for career contributions in suicidology), and the 2016 AAS “Linehan Award” (for suicide treatment research). He has been a consultant to the Centers for Disease Control and Prevention, the Institute of Medicine of the National Academy of Sciences, the National Institute of Mental Health, the Federal Bureau of Investigation, the Department of Defense, Veterans Affairs, and he now serves as a “Highly Qualified Expert” to the U.S. Army’s Intelligence and Security Command. Dave is a Board Member of the American Foundation for Suicide Prevention (AFSP) and serves on AFSP’s Scientific Council and the Public Policy Council. He is a Fellow of the American Psychological Association and is Board certified in clinical psychology (American Board of Professional Psychology). Dave maintains a private clinical and consulting practice in Washington DC; clinicians can get trained in the CAMS evidence-based treatment at https://cams-care.com/ |
|
W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Dr. Keith Sutton: (00:22)
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the Director of the Institute for the Advancement of Psychotherapy. Today, I'm speaking with David Jobes, Ph.D., who's a Professor of psychology and Director of the Suicide Prevention Laboratory, as well as Associate Director of clinical training at the Catholic University of America. David's also an Adjunct Professor of Psychiatry, School of Medicine at Uniformed Services University. He's published six books and numerous peer reviewed journal articles. Dave is a past president of the American Association of Suicidology, and he is a recipient of various awards for scientific work, including the 1995, AAS "Schneidman Award" early career contribution to suicidology, the 2012 AAS "Dublin Award" for career contributions in suicidology, and the 2016 AAS "Linhman Award" for suicide treatment research.
Dr. Keith Sutton: (01:29)
He has been a consultant for the Centers of Disease Control and Prevention, The Institute of Medicine of the National Academy of Sciences and The National Institute of Mental Health, The Federal Bureau of Investigation, The Department of Defense Veterans Affairs, and he now serves as a highly qualified expert to the U.S. Army's Intelligence and Security Command. Dave is a board member of the American Foundation for Suicide Prevention and serves on AFSP's Scientific Council and the Public Policy Council. He's a fellow of the American Psychological Association and he is board certified in clinical psychology. Dave maintains a private clinical and consulting practice in Washington, D.C., and clinicians can get trained in the Cams Evidence-Based Treatment, @camscare.com. Let's listen to the interview: "Well, hi, David. Welcome. Thanks for joining today."
Dr. David Jobes: (02:24)
Hey Keith, it's good to see you.
Dr. Keith Sutton: (02:25)
Yeah. So I reached out to you, cause I'm familiar with your measure, which I know you've also turned into a full on treatment, but the Suicide Status Form is something that I've been using for some years, and it's just very comprehensive, and I use it with clients and also when I'm teaching interns and associates.
Dr. Keith Sutton: (02:45)
And so I wanted to, you know, learn more about kind of what's going on in the field regarding suicide and suicide prevention and treatment. And I know this is an area that's, you know, sometimes very scary for a lot of clinicians, and I myself have always had that question about like, you know, when you're figuring out should I hospitalize or not, but before we kind of get into all that, I always like to hear about kind of your path and how you got to this place, of the work you're doing and what you're thinking about. Just kind of your evolution of ideas.
Dr. David Jobes: (03:14)
Well, first off I'm, I'm grateful to be on the podcast. So thanks for reaching out out. I have a passion for this topic. I've been at it ever since graduate school. So I got into suicide prevention and then clinical psychology pretty much cause I was an underachieving college student that wanted to get into a doctoral program. Mm-hmm. And so I got myself into a master's program to get a little bit more competitive for a PhD clinical psych program. And my professor in psychopathology was a guy named Lanny Berman, and he was a major player. He's retired now, but he was a major player in the field of suicide prevention back in like 1981 or '82. Wow. So I got into it as sort of a means to an end then as I started learning from him and about the field, it absolutely became my focus and I've never looked back.
Dr. David Jobes: (04:09)
It really is one of these things, you know, people, I was just at a conference and we were at a table and so I say, oh, suicide prevention, what a bummer. It's like, yeah, saving lives really cool. You know, I just look at it at a really different way, but I fully understand that people are petrified, worried, scared, anxious about working with suicidal clients and patients. And, that's really been, my mission is to kind of help clinicians feel more comfortable and to know that there are actually things that are effective, that work that are not widely used.
Dr. Keith Sutton: (04:39)
Yeah. It's so needed. Definitely great.
Dr. David Jobes: (04:43)
So I got into the business of psychological autopsies. That was my original research area in graduate school. And that was a little esoteric. So, I really wanted to get into a clinical focus.
Dr. David Jobes: (04:58)
I did my internship at the BA hospital in Washington, and then I took a job at Catholic university in the counseling center and that's really where the work kind of got started in earnest. My director was saying, I want to have a good way to assess suicide risk, and not let any of the clients fall through the cracks. Yeah. And so that was really the Genesis of the suicides status form, was an assessment tool that was meant to, you know, be user friendly for both the patient and the clinician, and psychometrically valid and reliable. And then we developed a tracking approach and then long story short, we did a lot of assessment work for, you know, maybe 15, 20 years, published a bunch of papers. And then, quite literally, Marshall Linehan, the developer of Dialectical Behavior Therapy, cornered me at a conference and said, you need to get outta the assessment business again to treatment.
Dr. David Jobes: (05:54)
And so that really began something I was kind of reluctant to do, which was again, treatment research. Yeah. But in the last 20 years, we've done a bunch of studies. There are now five published studies at the Cam's Intervention, a new meta-analysis of nine studies. This came out this year. So the evidence-base has been quite robust and it's comes at a time Keith, when the field of suicide prevention is sort of exploding, and it's very fluid and very exciting, and also challenging at the same.
Dr. Keith Sutton: (06:25)
Yeah. And I know it's, you know, even in California here for the licensing boards are requiring a six hour training for clinicians in suicide, in addition to all the other training and so on. But it's really, yeah. Taking the forefront. It's very important.
Dr. David Jobes: (06:41)
That's a national trend where licenses across our disciplines are being increasingly asked to have specialized training in risk assessment treatment. The problem is a lot of that training is not evidence-based. And so that's a particular bias of mine. I know that there's more than one way of knowing in this work, but I really do believe in randomized controlled trials.I believe in, you know, evidence. And I'm afraid a lot of what clinicians are doing has no evidence whatsoever. And we're talking about life and death. So it's a pretty important thing for us to be talking about
Dr. Keith Sutton: (07:11)
Definitely. Well, so I'm wondering, should we talk about the, you know, aspects of suicide kind of further, or I'm very interested in learning about the model. I hadn't known, I knew about the status form, but I hadn't known about the model until recently and just got your book, the "Managing Suicidal Risk the Collaborative Approach."
Dr. David Jobes: (07:31)
I think I could talk sort about the field and then, so where does cam, where does cams the intervention fit in? You know, we have been struggling for decades as the suicide rates have just gone up over the last 30 years, until 2019 and 2020 that the numbers are actually coming down a bit. Wow. But one of the things that's really interesting about that is that younger people and young people of color are actually having more idea and greater rates, middle aged white guys, like me, our rates are actually coming down in the last couple of years. So there's a sort of re allotment interesting, of some of the fatalities. And then what a lot of people don't know is that there's about 1.4 million attempts, and there about 12 million American adults in 2019, which are the most recent data from SAMSA, that have serious thoughts of suicide.
Dr. David Jobes: (08:28)
Yeah. And we add in the teenagers from the CDC's Youth Risk Behavior survey, that's another 3 million. So we've got 15 million Americans in a calendar year with serious thoughts of suicide in the 30 days prior to taking that survey. And a lot of people don't realize that from a suicide prevention standpoint, that's really the problem. I mean, we wanna of course, remove and reduce the attempts and deaths. 15 million people is a massive group of people. And a lot of clinicians don't know that the population is that large.
Dr. Keith Sutton: (09:05)
Yeah. Something that's so common that that many people feel.
Dr. David Jobes: (09:09)
Yeah. And then you have a lot of clinicians who are anxious about the topic, who won't see suicidal clients. That's interesting because they're Out there.
Dr. Keith Sutton: (09:21)
Yeah. Or maybe don't ask about it with their clients.
Dr. David Jobes: (09:23)
Well, there there's that, you know, "Don't ask, don't tell" kind of approach. And so that's really a big policy piece that I'm passionate about. And I live here in Bethesda, but I work in D.C. My university is in Washington and I'm on the public policy council of the American foundation for suicide prevention. So we go to the hill, we fight for legislation and fight for mental health and suicide prevention legislation. And that, that domain in that area is super hot right now. So there's a lot of movement in that space.
Dr. Keith Sutton: (09:53)
Yeah. So I'm interested. I mean, you know, sometimes when I think about working with my clients with where there's suicide, you know, that oftentimes for suicidal ideation, you know, somebody may be thinking, but they don't have a plan or they don't have intent of going through with it. But sometimes the suicidal thinking is almost a way of soothing of thinking, "Oh, if I was dead," or even fantasy or imagining to kind of decrease the internal distress.
Dr. David Jobes: (10:21)
Yeah, of course.
Dr. Keith Sutton: (10:22)
And then, but I also know that, you know, in some of the research that, you know, oftentimes when somebody does make a suicide attempt, it's kind of sometimes in an impulsive moment. And I know a lot of the safety planning kind of interventions are trying to help folks just get through those moments. And sometimes I ask clients, you know, zero to 10, how much are you thinking about wanting to not be alive or kill yourself?
Dr. Keith Sutton: (10:43)
And then zero to 10, you know, whether you're actually going to do something. And, but I always ask too, and what's the highest in the last week or so. Cause the client in the session can say, "Oh, I'm at a one. I wouldn't actually do anything." Then you ask what was the highest this week? And they say, "Well, on Tuesday I was at an eight and I was, you know, looking up was to kill myself on the internet." Um, cause it can be a little deceiving when the clients do an okay in the moment with you, but they've been having a hard time, and maybe might not share that.
Dr. David Jobes: (11:12)
Yeah. I mean, what you're speaking to is actually a fascinating area that is remarkably understudied. So for a lot of clinicians, suicide ideation is like a zero one, you know, suicide ideation no suicide ideation, like a binary thing. And of course, as you're describing as much more complexity to it than that, but it's remarkably understudied, I'm just saying this as somebody who's been in the field for 38 years. So we actually have a research team that's sort of like trying to look at the Genesis, the etiology, the maintenance the different kinds of patterns of the ways that people ideate. What are the components of ideation, and really trying to break all that apart and understand it a lot more. The way I think about clinical suicidology is that there is a need for screening, assessment, management of acute risk, and then treatment of suicide.
Dr. David Jobes: (12:07)
And so you're describing variations of, of those domains, but I really that a lot of clinicians don't do anybody a favor by not screening for risk. And there are gonna be people that are, you know, deny that they're suicidal when they actually are or people who are not suicidal that say they are so that's a conundrum, but a simple screening like the ASQ or the Columbia Suicide Severity Grading Scale is free. It's available. Then you know, that something is on board that we need to work with. And then the assessment is basically variations of what you described. And in my intervention, a big part of the intervention is an assessment tool called the suicide status form, that's completed collaboratively sitting next to the patient, or in pandemic times, on a screen in the fillable PDF, I'm sharing my screen, you're looking at the SSF, I'm filling it out for you.
Dr. David Jobes: (12:59)
And you are telling me exactly what you mean in the ratings and the different qualitative responses that we take. So we really mean in the, in our approach to be therapeutic in our assessment. So when we go through the SSF, a lot of times the patients are surprised how validated they feel and because we're nonjudgmental, and we're collaborative empathic. We are really trying to create a space where they can unpack what it means for them to be suicidal. So we ask about reasons for living and reasons for dying. We ask about their pain and stress and agitation, their hopelessness, how they feel about themselves. And then we ask about risk and warning signs, like history and attempts and so forth. And then what we find at the end of that process, Keith, is that we're like in a position to say, okay, I'd like to keep you out of the hospital but to do that responsibly and thoughtfully, we had to develop a stabilization plan.
Dr. David Jobes: (14:01)
Which means we have (incoherent) means, we have to think of different ways of problem-solving. We have to give you resources to reach out for help. It's much like the safety plan intervention. And then we're gonna identify two problems that you're telling me are at the root of why you wanna kill yourself. And in cams, we call those Drivers, and we can treat drivers with whatever. I know that you know a range of therapies, and you're very well trained. So you can use CBT, or you can use behavioral activation, you could use psychotherapy, you could farm it out to a couple's therapist. You could bring in a provider that, you know, is prescribing medication. So whatever interventions treat Drivers is what CAMS is about. So in that first session, we've done a therapeutic assessment.
Dr. David Jobes: (14:50)
We've got a stabilization plan, we've hit the pause button on taking your life and hopefully are in a process then of identifying, targeting, treating Drivers. So over interim care, we work specifically on these problems, and it's not that we eradicate, you know, a typical Driver -- my wife is leaving me. My wife is leaving me and I have intrusive thoughts from combat and Iraq. We're not necessarily gonna get the wife not to leave. We can try or we might have do some grief work about the loss of that relationship. We aren't necessarily going to reduce PTSD in a matter of six or eight sessions, but we can start (incoherent) exposure or EMDR or whatever intervention that you prefer. And in CAMS, what we do is we shift their relationship to suicide just enough where they see that they've got some alternatives and they don't have to kill themselves to get their needs met.
Dr. Keith Sutton: (15:50)
Yeah. There could be some way out of this pain.
Dr. David Jobes: (15:54)
Yeah. And that's really what the meta-analysis finds, is that we're decreasing hopelessness, we're increasing hope. Ideation tends to drop in six or eight sessions, overall symptom distress is going down, and the patients finding a way of getting their needs met differently, and can move on. And so that's the gist of the CAMS intervention. And it sits among a handful of other interventions that have been proven to work in randomized control trials that most clinicians have no idea about.
Dr. Keith Sutton: (16:26)
Yeah. No, it's yeah. I don't think that these things are brought up or covered or really in the forefront, a lot of focus on safety planning. And I think there's even some old thinking around suicide contracts and having the client actually contract to not harm themselves or kill themselves
Dr. David Jobes: (16:43)
Which never made sense and did not work.
Dr. Keith Sutton: (16:46)
Yeah. Yeah. And it not working, then the person just went more underground rather than really talking about it.
Dr. David Jobes: (16:54)
But that's a great example because back in the day, when I was using no harm contracts, I did it because it was the standard of care made no sense, it's invalidating, it's coercive, it's controlling. And if you don't sign my no harm contract, you're gonna go to the hospital. And as we're gonna talk about hospitalizations are probably more (incoherent) than they are helpful. So we really need to think differently about the way a lot of us were raised.
Dr. Keith Sutton: (17:18)
Yeah. It's something. I was actually in a workshop I was teaching the other day just around kind of the stance of therapy and collaboration that, you know, part of collaboration is having respect for the other person's individual choices. And also, and of course, therapists can get very scared when they're is talking about suicide fidelity, then may view something, say coercive, trying to say, well, I need you to contract to not do this or so on rather than kind of, you know, having the boundaries and saying like, gosh, I, you know, would really like to keep you alive and let's create these changes, but, but still kind of knowing where the therapist ends when the client begins, and the client is gonna make their own choices that they might make, we might need to step in, and sometimes yeah. Hospitalize or something like that. But also that not trying to kind of take over for them.
Dr. David Jobes: (18:05)
The pillars of CAMS are empathy, collaboration, transparency, and honesty, and being suicide focused. So we talk about that kind of thing. Very openly. So I might say to you, Keith, you know, as a provider here in Washington, DC, if you're in clear and in danger, I may have to have you go to the hospital, even whether you want to or not. And I'd rather have to do that. Here's the law and I'll hand them a copy of the DC mental health act with a section about clearing imminent danger highlighted. So they can see exactly what I'm required by my duty as the licensed provider to comply with, so we do that so that the client then knows what they're getting themselves into. And to me, it's like giving up the playbook, you know, it's like putting my cars in the table face up because I want you to know what the implications are of what you're describing.
Dr. David Jobes: (19:02)
And if we both don't want you to go to the hospital, then let's do a thoughtful stabilization plan. Let's get the firearm secured and out of the home. And let's pursue this treatment that's designed to save your life. Why wouldn't you wanna do that? Yeah. And so there's a, you know, a fair amount of motivational interviewing a little paradoxical work. But it tends to be something that, that the patients that we see, they, like we've got data that they like it more than usual care. And we're are trying to keep somebody outta the hospital, which usually is a goal that many patients have some don't and that's a different kind of patient.
Dr. Keith Sutton: (19:38)
I was gonna say that transparency, I think, is so important because sometimes people are reticent to talk about things, you know, even just having some thoughts because they're worried they're gonna get hospitalized. So yeah, I always use that too, of being very, kind of clear about like what would lead to hospitalization or not so that ultimately they can make the choice of what they wanna say or not say and not get surprised, but also kind of it even opens up for sharing more once they know kind of where the lines are of what may trigger, me needing to take action.
Dr. David Jobes: (20:10)
Yeah. Two thoughts on that. One is that back in the day, when I was working as a psych tech and an inpatient unit, people are hospitalized for months and months and months, you know, regularly. Now people are hospitalized for about five or six days and some are hospitalized for two or three days. And they're not getting really any treatment outside of medication, and medication doesn't help much with suicide at risk. So that's point one, point two is that, you know, really with this kind of transparency, and discussion, we're creating, sort of a dynamic in which the patient's view of things is validated without signing off and saying, yeah, you should go kill yourself. And a lot of patients then feel empowered to be a part of the treatment. And so, to me, you give up the illusion of power over this person,
Dr. David Jobes: (21:05)
But you gain credible influence and credibility. And you're side stepping the whole power struggle about whether you can or can't kill yourself. And then what I'm sort of known for, or infamous for saying is that, you know, "You can kill yourself later," but you can't kill yourself while in the treatment because it blows the treatment. Or a little reverence from DBT. Then I'll also say, you know, and why wouldn't you give this treatment a run because you can kill yourself later. Which is true. And so that kind of thinking or that kind of way of talking about we know from paper that came up about three years ago. A small but important study of clinicians, working prior practice and patients who didn't tell their therapists, they were suicidal, cause they didn't wanna go to the hospital -- 63%. So somebody is like, "Well, how are we gonna save lives then? If people are afraid to talk about this, and clinicians are afraid to deal with it?" So, that's really the mission, is to get clinicians to think this is not out of your wheelhouse. You can do this work. You don't have to refer them to the real doctors, the psychiatrists who know much less about treating suicidal risk than most psychologists and social workers and licensed professional answers do.
Dr. Keith Sutton: (22:30)
What I think you were talking about too, that aspect of empathy. And I know as I've been training others and I'm sure I've had this in my own experience too, that when this gets brought up, oftentimes the therapist can get very scared and, and will sometimes shift away from more of an empathic kind of connection to like, okay, now we're into protocol. My, and you know, kind of after the person saying like, oh my gosh, my wife's leaving me. And I just want to kill myself and stuff. Instead of saying like, oh my gosh, sounds really painful. They go into, oh, you wanna kill yourself? Like how long have you been thinking about this? And kind of almost shifting in the mood, which, you know, again, can oftentimes, you know, feel like the client is feeling dropped by the therapist, cause it's no longer validating.
Dr. David Jobes: (23:15)
That's because the client's being dropped by the therapist. They're they're being gotten rid of. And they sense that because you're thinking about where can I get a bed for two or three days. And then they go to the hospital for two or three days and they get started on medication. And some of these meds don't work for a number of weeks, and their life has been significantly disrupted and they sat through a couple groups that they don't find very helpful and they've watched a lot of TV and then they get discharged, and what exactly have we done for them? And the fact is that around the world, there's replicated evidence that, even a single hospitalization, but ultimately any hospitalization the week to two weeks, the four weeks up to six months to a year after that hospitalization, there's a significant increase in risk.
Dr. David Jobes: (24:02)
So there's a psychiatrist in Melbourne, Australia who talks about nosocomial suicides, which are suicides caused, he argues, by the hospitalization, so he's not popular in the psychiatric community, but yeah, it does go to a, you know, a strong view that Marsha Lenahan had, which is that hospitalization is virtually never helpful unless somebody's acutely psychotic. And so my goal is not to bash hospitalization. Maybe some of your podcast, you know folks are on working in patient care. My concern is hospitalization that doesn't have suicide focused intervention. We have a clinical trial right now at the Cleveland Clinic and Mass General Hospital where older teens and young adults are being hospitalized at MGH and Cleveland Clinic. And while they're on the inpatient unit, they're getting up to six IV doses of ketamine. So low dose IV dose of ketamine.
Dr. David Jobes: (24:54)
And when it works, it's pretty extraordinary and it works. I'm not a big fan of medication, but ketamine for some people is really, powerful. They start camps. So the trial is 140 of these pretty seriously suicidal people on an inpatient unit who are either getting cams. I'm sorry. They're either getting ketamine or saline. And the saline is control but everybody's getting cams. One session before they leave and up to eight sessions, post discharge done on tele-health because that high risk post discharge period is really concerning. So now for that hospitalization, you've gotten a medication that maybe facilitates this evidence based intervention that gets started in the inpatient unit and is then traverses the high risk post discharge period. That to me is a good hospitalization.
Dr. Keith Sutton: (25:49)
And have the findings been kind of completed or is it in process currently?
Dr. David Jobes: (25:54)
We just started, yeah. You know, I think about Walter Reed, you know, which is just over here in Bethesda, you know, Walter Reed had a program that Marjan Holloway developed for a five or six day stay where you're getting the Cognitive Therapy for Suicide Prevention Intervention developed by Erin Bed Brown. So for your five or six days stay, you're actually getting a treatment that's been proven to work. And by discharge, oh, you have something that you didn't know, before you were admitted. So this is the way hospitalization should be, but my argument is there's a lot of people that are hospitalized out of clinician, fear and anxiety, mostly about (incoherent) and just not wanting to have somebody kill themselves malpractice and somebody dying. That could be easily inappropriately and better handled on an outpatient basis.
Dr. Keith Sutton: (26:38)
Yeah. I mean, I think that's a good question too about, you know, I think that's something I always struggle with When there's a situation where I'm worried about, should I hospitalize or not, and of course, going through all the, you know, aspects, but you know, sometimes there is a place where it feels like, gosh, I don't know if this person's gonna be safe. They're not necessarily saying I'm gonna do it. Or they're saying there's a high likelihood, you know, it would be clear-cut. If they're saying, oh, I'm gonna go home tonight and you know, do this and to take my own life then of course it's like, yeah, no brainer. Like we need to go for hospitalization. But when they're like, mm, I don't feel like living, but I don't know. I don't know what I'm gonna do. They have a plan or thought of something that actually sounds, possible. And as the clinician trying to figure out like, you know, yeah. What, is the best way to go about this? Do you have any like guidance or thoughts on those kind of ambiguous situations where it's not so clean cut?
Dr. David Jobes: (27:36)
I mean, I'm not very objective, I've used CAMS because you use CAMS, you've at least ensured that the environment has been made safer. That lethal means have been secure. They have a stabilization plan. They'll probably have a crisis support plan with somebody significant in their life. Um, you'll have a sense. Are, are they able to work on their drivers? Are you making therapy attraction? Um, or are they really dysregulated and feeling really shaky last time I pass by somebody's 20 years ago. You know, I just don't do it. And it's not like I have a huge caseload, you know, not compared to somebody like you, but I do have a handful of patients. I do see high risk patients. And I just hardly ever hospitalize somebody because I find there's a way that we can talk about it.
Dr. David Jobes: (28:20)
very candidly. Very appropriately within the guideline of our duty as licensed providers, where hospitalization would really be the absolute last ditch thing that I would ever do. And last time I came close, it was probably 10 years ago. So I, you know, I think about a study Keith, that we did at university of Nevada Reno in the counseling center and the study was looking at cams and dialectical behavior. So it was a clinical trial. It was funded by NIMH. And we saw 62 students, some of whom are very suicidal not a single hospitalization. Meanwhile, I'm consulting to George Washington university hospital. Here in BC and they would hospitalize somebody on the recommendation of a resident advisor. They hospitalized kids left and right. Anybody who whispered suicide boom in a hospital, and I'm working at both these counseling centers and saying, you know, what is this, you know, two very different cultures. One obsessed with litigation. And, you know, they're just on the road from the White House. So they're kind of high profile university, but they are mostly in a CYA fear-of-litigation mode and another counseling center. That's using evidence-based interventions where not a single student was hospitalized.
Dr. Keith Sutton: (29:39)
Wow.
Dr. David Jobes: (29:40)
So that's my point of comparison.
Dr. Keith Sutton: (29:43)
Yeah. I mean, I always kind of, you know, I've had a couple clients over time, you know, where sometimes, you know, we've got the safety plan, but they're like, "I don't know if I would call them. I don't know if I would use these things. Like, I'm just feeling so bad. Like I don't wanna live," and it almost kind of shut down. I think that for me has been the scariest kind a situation, where they're kind of, they can't, they don't know if they can keep themselves safe. They're kind of feeling unwilling to engage in any of the tools or so on. And, you know, sometimes first of my clients, I kind of use a metaphor that, you know, I think about like the flu sometimes, like when you've got the flu, like, you feel horrible, you feel like you're never gonna feel good again, you can't remember feeling, you know, when you were healthy before, but eventually as things get better. You don't quite realize. So I kind of hold the hope for my clients, even if they don't have it, but oftentimes too sometimes that they're just kind of in the shutdown place, which I know for myself, it's been scary and kind of questioning hospitalization, or kind of looking at when there's maybe not the engagement, or they're just so overwhelmed they kind of shut down.
Dr. David Jobes: (30:48)
Well, I think if you are transparent about it, all you say, you know, really my options are limited. And we may have you go to the hospital. It's not my preference, but you know how the law works, and I can't break the law and I feel like you're venturing into imminent, you know, risk. But I feel like clinicians go right to that. And think of it as their first response versus the absolute last ditch, nothing else is gonna, you know, potentially save this life. And that's the thing I think we're talking about here. I'm not saying never hospitalized, but I'm saying, why are you hospitalizing? And what's gonna be the outcome? Is it gonna be better for this person? It may well be better, but a lot of times it makes things worse.
Dr. Keith Sutton: (31:33)
Yeah. It's not really gonna do much except maybe get them through the next few days is the way, I guess I think about it. You know.
Dr. David Jobes: (31:40)
I had a patient, here's a story. I had a patient who overdosed went to group, told the group, she just overdosed. The therapist called me. I went over and picked her up in my car, drove over to a major hospital in the Washington D.C. area, sat with her in the emergency department until two in the morning, she was admitted. I got a call from the social worker, 11 o'clock the next morning saying they were ready to discharge her. She met with her psychiatrist for 20 minutes. Who said to her, next time you feel like overdosing your medication just don't do it.
Dr. Keith Sutton: (32:15)
Oh boy.
Dr. David Jobes: (32:16)
She said, okay. And you wrote up her discharge orders. This is a board-certified attending psychiatrist at a major hospital in Washington D.C. And that was probably 18 years ago. So, you know, you just know it's actually more than that. It's about 25 years ago. So, you know, things have not necessarily evolved from there, getting better. And so I, you know, I don't mean to be radical or provocative, but I do mean to have people think about what's the goal and what's in the patient's best interest.
Dr. Keith Sutton: (32:51)
Well, and even kind of sitting in that place of discomfort before jumping to get to the other side of just saying, okay. Hospital lies, but trying to take the time to understand and look at all the aspects or so on. I think, cause kind of you're saying that some people might be just jumping right to that. And again, it's not like the hospital is gonna be some magic fix
Dr. David Jobes: (33:11)
And well, I think we think it is. And I think that we think that medication's gonna help more than does, it doesn't really help that much. It may help with depression, it may help with psychosis. Now I would not have a patient be referred for medication but the evidence on the SRIs is very mixed. Clozapine is the only medication that's been approved by the FDA for an anti-suicide agent, an atypical antipsychotic and not widely used one RCT, no replication cancer replicated five times in RCTs, and nobody's ever heard of it. So, we have a bias to think that medicine's more effective than it is for suicide risk than it is. And that something magical must happen in the hospital.
Dr. Keith Sutton: (33:52)
Yeah. Like there's some pill, right. That's gonna gonna fix it. And you know, if there was, we would've gotten that, you know, way ahead of time, or oftentimes with the clients that are suffering. I think too, that another detriment is also about, you know, I've talked to some clients about maybe doing an intensive outpatient or doing an inpatient 30 day program or something like that. And I had one client recently and he said like, oh no, I did that before. And then when I explored it, he had been hospitalized for 48 hours or 72 hour hold. And so he was like not interested in going into any more intensive treatment. So I had to do some education around how there's some differences around that. You know, significant differences in what that looks like, because that negative experience led him to be kind of resistant to more intensive treatment.
Dr. David Jobes: (34:41)
Yeah. I'm talking to a guy in Ohio who's, I think he's a LPC, but he's got a business mind, and he's inherently trained to dialectical behavior therapy into CAMS, and we've been talking very seriously about developing clinics where the clinicians would be trained up in DBT in CAMS, and CAMS would have all the ideation because it's the best treatment for ideation and DBT handles all the behavior and that's all they would see. And as akin to in Denmark, they have different regions of the country and every region has a suicide intervention center. And if you're a dangerous citizen, you get 12 sessions of suicide specific care, as a citizen of Denmark. And at the national population level, there's been research showing that's an effective intervention. So, you know, that model is to avert emergency department visits, hospital stays, or people coming out of the hospital, and this guy's convinced that he can actually make this be an effective clinic and franchise it and sort of propagate it. I think it's so much more cost effective than hospitalization.
Dr. Keith Sutton: (35:52)
Yeah Definitely. No, I was wondering too, I don't know if you're familiar. One of the earlier interviews, for this podcast, I also interviewed a Guy Diamond attachment-based family therapy for depressed adolescents and his work with suicide. And I was just, you know, that part of the idea is that by kind of helping to shore up the attachment figures, particularly with these adolescents and their parents, you know, will that is been found a decreased anxiety, depression and so on. Yeah, I was wondering on your thoughts about kind of, yeah that social connection, or the family work or so on in these situations where you've particularly got adolescents or such, or even yeah. These college students.
Dr. David Jobes: (36:32)
Yeah. I'm a big fan of, of Guy Diamond, and of attachment-based family therapy. You know, what I think is, well, what I know is that we did a clinical trial with the us military infantry soldiers at Fort Stewart and Georgia and the soldiers in CAMS. If they had a significant other, a girlfriend or boyfriend, you know, a spouse, we would have them come in. And they would oftentimes, you know, sit and learn about the drivers and learn about the stabilization plan. And so, as you bring 'em back, and one of the things that we found after that trial was that married soldiers did better in CAMS, increased resiliency in overall symptom distress, more than treatment as usual treatment as usual never brought in a spouse. So now we do it all the time. We've got two new funded and IMH studies there with teenagers, and there's a crisis support plan idea that was developed by Craig Bryan, who's at Ohio state, and we now are having all the kids get a crisis support plan by a parent, our grandparent, or significant another, so that they can support the treatment that the kids are actually quite amenable to.
Dr. Keith Sutton: (37:43)
Yeah. Yeah. Well, and oftentimes too, when they have somebody, they don't feel alone, you know, and if they're only seeing the therapist maybe once a week or something like that, at least they have some other supports in between. That's great. And I'm wondering too, you know, I think the tough thing, so I think I shared a little bit with you when we talked on the phone about setting up this interview. Recently, I had a colleague who, took his own life, who passed away. He unfortunately, you know, suffered from bipolar disorder, which, we're pretty sure which had a later onset in his life. And it was unfortunate, I mean, they had, his family had tried to hospitalize. Somebody knew what to say. He had even been to therapy the day before and so on.
Dr. Keith Sutton: (38:29)
And so, you know, and I think that that's one of the scariest things too, because it was very unlike the person. So, you know, I think that, you know, he wasn't himself from what the people had been around him in a few weeks or so on. So that kind of our mind turning against ourselves is so scary. But I mean, there was, I guess, a determination there, around, you know, ending it and despite the interventions that we're trying to be used, or even, you know, again, knowing what to say to the hospitals. I just was wondering about your thoughts on that, that despite all interventions, that sometimes people do make that decision. And, I don't know.
Dr. David Jobes: (39:08)
Yeah. I think the majority of people that take their lives don't do that, but a subset of course, do. You know, they're not dropping hints. They're not in a place where they're being rescued. They don't mess around with pills or razor s. They get a gun or they hang themselves, or they jump over seven stories. You know, so they do a lethal method and they're not rescuable and they don't, and they aren't interrupted. Years ago, I lost a colleague at my university. Literally my friend and colleague across the hall, who's a professor in our department. And, you know, in hindsight, you know, there were little things that I could have thought, oh yeah, that wasn't great. I kind of wish I would talk to him as he hung by my door there that one day.
Dr. David Jobes: (39:56)
Yeah, but it was really something that mostly was not, you didn't see coming from a mile away those happen, but the majority, I would say, especially people who are talking to a therapist, you know, are not out of the blue. And this is a contentious topic among ologists. Are there, is there such a thing as a sudden suicide where there isn't sort of this gradual sort of ramping up an attempt or completion behavior. I did a webinar last week with Craig Bryan and Craig was saying, he thinks in the research they do with, ecological momentary assessment, but there's a small subset of people who start the behavior and then sort of realize that they're taking their life. And he said it was akin to being on a balance beam and your arms start to move.
Dr. David Jobes: (40:50)
And all of a sudden you're starting to go and like, and then you realize you're falling. And so I'm thinking, hmm, that's really interesting. Thomas Joiner would say, there's no such thing as an impulsive suicide. Somebody has thought about in the past and put on a shelf, gets in a situation where they are suddenly dysregulated upset, agitated. They reach for it. Boom. I might argue that this ramping up actually can be compressed in a matter of minutes. But by the end of today, Keith, 130 Americans will have taken their lives, and a hundred percent of them will have suicidal thoughts. If they don't, they're certified as accidents. So the ideation, as I was alluding to early on is such an important thing for us to understand differently and better. And the complexities and nuances of it.
Dr. David Jobes: (41:41)
There are some people who idea at very high levels. This is the ecological momentary assessment data. Where people get beeped on their cell phones or, you know, on their Fitbits and they'll get a lot of data. And so people have very high levels and they'll have a good day and they have a drop, and then SIM has sort of low grade ideation and they have a really crappy day and they spike, and then there are people who are all over the place. Exhausted because they're being thrown around, you know, from suicidal, not suicidal, just regulated, upset, calming down. And that's the kind of resource that we're interested in doing is to really start to understand some of those patterns.
Dr. Keith Sutton: (42:24)
Nuances of that. I was really struck by, I recently did a complex PTSD certification with Janina Fisher online. And you know, in her talking about with complex trauma that oftentimes many individuals who have experienced this, you know, ideation was that way to cope. And, you know, when they were in this helpless stuck situation, particularly if it was childhood trauma, and kind of understanding from the clinician's viewpoint, the function of the ideation and how it's helping, or even if we look into structural dissociation and kind of parts work, as actually just my session before this working with a client, just she was walking down the street and she had to move outta the way cause of somebody and the thought came into her head like, oh, you should just kill yourself. And, you know, we were just looking at that part and then she starts beating herself up for having that thought, but this is a part and she struggles with trauma and throughout, but it's just this, you know, you don't deserve live or burden or whatever it might be. And it just pops in, but she's not actively suicidal or wanting to, but if she's oftentimes thinking about it several times a day. And so it's just part of her life and it doesn't feel good and that's part of the treatment. But I think that was just something significant as I thought about and hearing about just that this is sometimes part of the person's experience rather than, you know, again, that red alert, which again, still needs to be taken seriously and assessed.
Dr. David Jobes: (43:54)
Yeah, but you didn't hospitalize her. You let her mentalize around it and think about it and look at it and understand it. And this, the idea of the functional utility that you learn in the trauma training is absolutely on the money. So that we, you know, we don't rip this away from somebody before they're ready to let go of it. How is that helping them? And for some people, this is like a warm blanket. You know, that it comfort them. It gives 'em a sense of control. They feel empowered. Other people react strongly. What's not to like about that in a certain kind of psychological sense. If we understand that and don't rip that blanket away from them, then they're in a place to kinda listen about alternatives. And that's really how I think about CAMS, or about good psychotherapy, is that we don't react purely outta counter transference. You know, we listen to the functional utility of the words and what it means to this person. And then we pose, you know, sort dangle the carrot of like, well, what would it look like to, to do this? And, and, you know, if we can tolerate that and meta communicate. You're not frightening me. You know, this is a scary topic. But I will be with you in the struggle. And that, that goes so far for the person that struggles with suicide, because they're so expecting to be gotten rid of. When I was younger, I worked with the psychoanalyst named, Maltsberger very famous guy in the field.
Dr. David Jobes: (45:34)
He's like a pioneer. And he was the pioneer that wrote this sort of wildly provocative paper, like in 1978 or something like that, about Contra transference hate in the patient. And archive general psychiatry. It was hugely controversial, so I got to write this book chapter with him and he was one of my heroes and, and we wrote about the therapist Voer. You know, very professional on the outside looking in. Oh, you're really struggling. And there aren't you. You know, but not really engaged. Because of their empathic dread. And so we, then we champion this idea of the therapist participant, with empathic fortitude who would go into that space and people be like, yeah, no. It's too upsetting. I'm just gonna in the hospital. So that's when I looked on it now at 63, and think back over the last 30, some odd years, you know, that's part of CAMS was to kind of back the clinician quite literally to sit next to the patient and use an assessment tool to objectify the suicide risk and start to mentalize. And deconstruct what means for them to be suicidal to then hit the pause button and look at alternative ways of coping, and then treating the things that they say, make them wanna kill themselves. And so because in (incoherent) fortitude really kind of bounced off people's in one ear or not the other. CAMS got us in a place where we were able to say, let's take a seat next to the patient with their permission or online. And we'll pull up the SSF and you tell me what it's like to be you, so I can see it just like you do. I'm a rorschach-er from way back.
Dr. Keith Sutton: (47:27)
Understand your experience. Yeah. Well, and it, the way I think about it too, is that, um, you know, James Kim, who I've worked within our family therapy approach, talked about the hard side and the soft side of hierarchy and kind of, this from strategic family therapy kind of background, you know, for parents, hard side rules, consequences structure, soft side, you know, who students whom who's in charge of good things good times, but also who can handle the hottest topics and to truly kind of have that, that benevolent authority or that positive attachment that we, as the therapist need to be able to handle the hottest topics and be able to stay present with our client, with what they're bringing in. And I forget, I think it was an article. I learned one of my practicums of the term psyche that kind of internal, emotional pain. And as you're talking about with the empathy that, you know, I think of Brown's little video on empathy that, you know, to truly empathize, we have to connect with that part of ourselves that has felt the way the other person has. And if we're connecting with that psyche ourselves, then that can become disregulating and then the person just wants to fix it or like hospitalized or whatever, cause it's, it's too overwhelming and they can't handle the hottest topic in those moments.
Dr. David Jobes: (48:41)
Well, that's exactly right. And then what people will say is like, well I from an ethical standpoint, I don't feel comfortable working with this cause I don't have the expertise. And you know, okay. Then get the expertise. You know, cause to me, it's akin to a primary care provider saying, "Keith, I'll give you a full physical, but you know, I just, I don't do the heart thing. Cardiac, you know, disease just isn't my wheelhouse. So you'll have to see a cardiologist for that." I don't think we can defend saying that we don't handle suicide risk, it doesn't mean that you have to become an expert. But at a minimum you can learn about safety planning. Or the national lifeline, or the national text line, you can learn about lethal means safety discussions and how to secure firearms and how to secure, you know, stashes of pills. Work out forbid you can learn intervene like CAMS or BCBT or CTSP or DBT. And you know, really be a part of the solution.
Dr. Keith Sutton: (49:42)
Well, I think it's so important to the model that you've got, because I think that the other aspect is the clinician feeling competent and needing to have that competent. Cause if they're not feeling competent, it feels out of control. It feels scary. They don't have a roadmap. They don't know where they are or where they're going. So, yeah, it's great. You know, I love the measure to kind of assess and plan and I I'm really looking forward to learning more about this treatment approach cause I think it's definitely something that's needed and something that's neglected because suicide and suicidal ideation is like, you're saying you can't avoid it in treatment in your work with clients. So you need to know how to learn it and, it would be, you know, kind of neglectful to say, well, I just don't do that. Because it's gonna come up, whether you screen for it or not.
Dr. David Jobes: (50:29)
Well, and ironically, most of us aren't trained. I mean, across mental health disciplines. Less than 30% have even an hour on the assessment treatment of suicide risk in graduate school, professional training programs. So I'm not pointing fingers and looking down my knows, I'm saying, yeah, we've got a problem. It's a training problem. I love training young people and clinicians in graduate school because they don't have attitude, they're scared, they wanna get it right. And they believe in evidence-based practices. And they can become expert in our intervention in lickity split.
Dr. Keith Sutton: (51:05)
They wanna know what to do, they want direction and some guidance and structure to it. Well, thank you so much for your time today. I really appreciate it. This is such an important topic and you know, yeah. I'm looking forward to learning more about your work and I'll link to your information on our website for folks that are interested, learning more, I'm sure we're doing trainings or workshops or things like that. I really appreciate it. Thank you for taking the time.
Dr. David Jobes: (51:34)
Thanks Keith. I appreciate being on the podcast and hope to see you again some time.
Dr. Keith Sutton: (51:38)
Okay, great. Take care. Bye-bye bye.
Dr. Keith Sutton: (51:42)
Thank you for joining us. If you're wanting to use this podcast or continuing education credits, please go to our [email protected]. Our podcast is brought to you by the Institute for the advancement of psychotherapy, providing in person and remote therapy in the San Francisco Bay Area. IAP provides screening for licensed clinicians through our in-person and online programs, as well as our treatment for children, adolescents, families, couples, and individual adult. For more information, go to sfiap.com or call 4 1 5 6 1 7 5 9 3 2. Also, we really appreciate feedback. And if you have something you're interested in, something that's on the cutting edge of the field of therapy, and think clinicians should know about it, send us an email or call us we're always looking for the advancements in the field of psychotherapy to help in creating lasting changes for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the Director of the Institute for the Advancement of Psychotherapy. Today, I'm speaking with David Jobes, Ph.D., who's a Professor of psychology and Director of the Suicide Prevention Laboratory, as well as Associate Director of clinical training at the Catholic University of America. David's also an Adjunct Professor of Psychiatry, School of Medicine at Uniformed Services University. He's published six books and numerous peer reviewed journal articles. Dave is a past president of the American Association of Suicidology, and he is a recipient of various awards for scientific work, including the 1995, AAS "Schneidman Award" early career contribution to suicidology, the 2012 AAS "Dublin Award" for career contributions in suicidology, and the 2016 AAS "Linhman Award" for suicide treatment research.
Dr. Keith Sutton: (01:29)
He has been a consultant for the Centers of Disease Control and Prevention, The Institute of Medicine of the National Academy of Sciences and The National Institute of Mental Health, The Federal Bureau of Investigation, The Department of Defense Veterans Affairs, and he now serves as a highly qualified expert to the U.S. Army's Intelligence and Security Command. Dave is a board member of the American Foundation for Suicide Prevention and serves on AFSP's Scientific Council and the Public Policy Council. He's a fellow of the American Psychological Association and he is board certified in clinical psychology. Dave maintains a private clinical and consulting practice in Washington, D.C., and clinicians can get trained in the Cams Evidence-Based Treatment, @camscare.com. Let's listen to the interview: "Well, hi, David. Welcome. Thanks for joining today."
Dr. David Jobes: (02:24)
Hey Keith, it's good to see you.
Dr. Keith Sutton: (02:25)
Yeah. So I reached out to you, cause I'm familiar with your measure, which I know you've also turned into a full on treatment, but the Suicide Status Form is something that I've been using for some years, and it's just very comprehensive, and I use it with clients and also when I'm teaching interns and associates.
Dr. Keith Sutton: (02:45)
And so I wanted to, you know, learn more about kind of what's going on in the field regarding suicide and suicide prevention and treatment. And I know this is an area that's, you know, sometimes very scary for a lot of clinicians, and I myself have always had that question about like, you know, when you're figuring out should I hospitalize or not, but before we kind of get into all that, I always like to hear about kind of your path and how you got to this place, of the work you're doing and what you're thinking about. Just kind of your evolution of ideas.
Dr. David Jobes: (03:14)
Well, first off I'm, I'm grateful to be on the podcast. So thanks for reaching out out. I have a passion for this topic. I've been at it ever since graduate school. So I got into suicide prevention and then clinical psychology pretty much cause I was an underachieving college student that wanted to get into a doctoral program. Mm-hmm. And so I got myself into a master's program to get a little bit more competitive for a PhD clinical psych program. And my professor in psychopathology was a guy named Lanny Berman, and he was a major player. He's retired now, but he was a major player in the field of suicide prevention back in like 1981 or '82. Wow. So I got into it as sort of a means to an end then as I started learning from him and about the field, it absolutely became my focus and I've never looked back.
Dr. David Jobes: (04:09)
It really is one of these things, you know, people, I was just at a conference and we were at a table and so I say, oh, suicide prevention, what a bummer. It's like, yeah, saving lives really cool. You know, I just look at it at a really different way, but I fully understand that people are petrified, worried, scared, anxious about working with suicidal clients and patients. And, that's really been, my mission is to kind of help clinicians feel more comfortable and to know that there are actually things that are effective, that work that are not widely used.
Dr. Keith Sutton: (04:39)
Yeah. It's so needed. Definitely great.
Dr. David Jobes: (04:43)
So I got into the business of psychological autopsies. That was my original research area in graduate school. And that was a little esoteric. So, I really wanted to get into a clinical focus.
Dr. David Jobes: (04:58)
I did my internship at the BA hospital in Washington, and then I took a job at Catholic university in the counseling center and that's really where the work kind of got started in earnest. My director was saying, I want to have a good way to assess suicide risk, and not let any of the clients fall through the cracks. Yeah. And so that was really the Genesis of the suicides status form, was an assessment tool that was meant to, you know, be user friendly for both the patient and the clinician, and psychometrically valid and reliable. And then we developed a tracking approach and then long story short, we did a lot of assessment work for, you know, maybe 15, 20 years, published a bunch of papers. And then, quite literally, Marshall Linehan, the developer of Dialectical Behavior Therapy, cornered me at a conference and said, you need to get outta the assessment business again to treatment.
Dr. David Jobes: (05:54)
And so that really began something I was kind of reluctant to do, which was again, treatment research. Yeah. But in the last 20 years, we've done a bunch of studies. There are now five published studies at the Cam's Intervention, a new meta-analysis of nine studies. This came out this year. So the evidence-base has been quite robust and it's comes at a time Keith, when the field of suicide prevention is sort of exploding, and it's very fluid and very exciting, and also challenging at the same.
Dr. Keith Sutton: (06:25)
Yeah. And I know it's, you know, even in California here for the licensing boards are requiring a six hour training for clinicians in suicide, in addition to all the other training and so on. But it's really, yeah. Taking the forefront. It's very important.
Dr. David Jobes: (06:41)
That's a national trend where licenses across our disciplines are being increasingly asked to have specialized training in risk assessment treatment. The problem is a lot of that training is not evidence-based. And so that's a particular bias of mine. I know that there's more than one way of knowing in this work, but I really do believe in randomized controlled trials.I believe in, you know, evidence. And I'm afraid a lot of what clinicians are doing has no evidence whatsoever. And we're talking about life and death. So it's a pretty important thing for us to be talking about
Dr. Keith Sutton: (07:11)
Definitely. Well, so I'm wondering, should we talk about the, you know, aspects of suicide kind of further, or I'm very interested in learning about the model. I hadn't known, I knew about the status form, but I hadn't known about the model until recently and just got your book, the "Managing Suicidal Risk the Collaborative Approach."
Dr. David Jobes: (07:31)
I think I could talk sort about the field and then, so where does cam, where does cams the intervention fit in? You know, we have been struggling for decades as the suicide rates have just gone up over the last 30 years, until 2019 and 2020 that the numbers are actually coming down a bit. Wow. But one of the things that's really interesting about that is that younger people and young people of color are actually having more idea and greater rates, middle aged white guys, like me, our rates are actually coming down in the last couple of years. So there's a sort of re allotment interesting, of some of the fatalities. And then what a lot of people don't know is that there's about 1.4 million attempts, and there about 12 million American adults in 2019, which are the most recent data from SAMSA, that have serious thoughts of suicide.
Dr. David Jobes: (08:28)
Yeah. And we add in the teenagers from the CDC's Youth Risk Behavior survey, that's another 3 million. So we've got 15 million Americans in a calendar year with serious thoughts of suicide in the 30 days prior to taking that survey. And a lot of people don't realize that from a suicide prevention standpoint, that's really the problem. I mean, we wanna of course, remove and reduce the attempts and deaths. 15 million people is a massive group of people. And a lot of clinicians don't know that the population is that large.
Dr. Keith Sutton: (09:05)
Yeah. Something that's so common that that many people feel.
Dr. David Jobes: (09:09)
Yeah. And then you have a lot of clinicians who are anxious about the topic, who won't see suicidal clients. That's interesting because they're Out there.
Dr. Keith Sutton: (09:21)
Yeah. Or maybe don't ask about it with their clients.
Dr. David Jobes: (09:23)
Well, there there's that, you know, "Don't ask, don't tell" kind of approach. And so that's really a big policy piece that I'm passionate about. And I live here in Bethesda, but I work in D.C. My university is in Washington and I'm on the public policy council of the American foundation for suicide prevention. So we go to the hill, we fight for legislation and fight for mental health and suicide prevention legislation. And that, that domain in that area is super hot right now. So there's a lot of movement in that space.
Dr. Keith Sutton: (09:53)
Yeah. So I'm interested. I mean, you know, sometimes when I think about working with my clients with where there's suicide, you know, that oftentimes for suicidal ideation, you know, somebody may be thinking, but they don't have a plan or they don't have intent of going through with it. But sometimes the suicidal thinking is almost a way of soothing of thinking, "Oh, if I was dead," or even fantasy or imagining to kind of decrease the internal distress.
Dr. David Jobes: (10:21)
Yeah, of course.
Dr. Keith Sutton: (10:22)
And then, but I also know that, you know, in some of the research that, you know, oftentimes when somebody does make a suicide attempt, it's kind of sometimes in an impulsive moment. And I know a lot of the safety planning kind of interventions are trying to help folks just get through those moments. And sometimes I ask clients, you know, zero to 10, how much are you thinking about wanting to not be alive or kill yourself?
Dr. Keith Sutton: (10:43)
And then zero to 10, you know, whether you're actually going to do something. And, but I always ask too, and what's the highest in the last week or so. Cause the client in the session can say, "Oh, I'm at a one. I wouldn't actually do anything." Then you ask what was the highest this week? And they say, "Well, on Tuesday I was at an eight and I was, you know, looking up was to kill myself on the internet." Um, cause it can be a little deceiving when the clients do an okay in the moment with you, but they've been having a hard time, and maybe might not share that.
Dr. David Jobes: (11:12)
Yeah. I mean, what you're speaking to is actually a fascinating area that is remarkably understudied. So for a lot of clinicians, suicide ideation is like a zero one, you know, suicide ideation no suicide ideation, like a binary thing. And of course, as you're describing as much more complexity to it than that, but it's remarkably understudied, I'm just saying this as somebody who's been in the field for 38 years. So we actually have a research team that's sort of like trying to look at the Genesis, the etiology, the maintenance the different kinds of patterns of the ways that people ideate. What are the components of ideation, and really trying to break all that apart and understand it a lot more. The way I think about clinical suicidology is that there is a need for screening, assessment, management of acute risk, and then treatment of suicide.
Dr. David Jobes: (12:07)
And so you're describing variations of, of those domains, but I really that a lot of clinicians don't do anybody a favor by not screening for risk. And there are gonna be people that are, you know, deny that they're suicidal when they actually are or people who are not suicidal that say they are so that's a conundrum, but a simple screening like the ASQ or the Columbia Suicide Severity Grading Scale is free. It's available. Then you know, that something is on board that we need to work with. And then the assessment is basically variations of what you described. And in my intervention, a big part of the intervention is an assessment tool called the suicide status form, that's completed collaboratively sitting next to the patient, or in pandemic times, on a screen in the fillable PDF, I'm sharing my screen, you're looking at the SSF, I'm filling it out for you.
Dr. David Jobes: (12:59)
And you are telling me exactly what you mean in the ratings and the different qualitative responses that we take. So we really mean in the, in our approach to be therapeutic in our assessment. So when we go through the SSF, a lot of times the patients are surprised how validated they feel and because we're nonjudgmental, and we're collaborative empathic. We are really trying to create a space where they can unpack what it means for them to be suicidal. So we ask about reasons for living and reasons for dying. We ask about their pain and stress and agitation, their hopelessness, how they feel about themselves. And then we ask about risk and warning signs, like history and attempts and so forth. And then what we find at the end of that process, Keith, is that we're like in a position to say, okay, I'd like to keep you out of the hospital but to do that responsibly and thoughtfully, we had to develop a stabilization plan.
Dr. David Jobes: (14:01)
Which means we have (incoherent) means, we have to think of different ways of problem-solving. We have to give you resources to reach out for help. It's much like the safety plan intervention. And then we're gonna identify two problems that you're telling me are at the root of why you wanna kill yourself. And in cams, we call those Drivers, and we can treat drivers with whatever. I know that you know a range of therapies, and you're very well trained. So you can use CBT, or you can use behavioral activation, you could use psychotherapy, you could farm it out to a couple's therapist. You could bring in a provider that, you know, is prescribing medication. So whatever interventions treat Drivers is what CAMS is about. So in that first session, we've done a therapeutic assessment.
Dr. David Jobes: (14:50)
We've got a stabilization plan, we've hit the pause button on taking your life and hopefully are in a process then of identifying, targeting, treating Drivers. So over interim care, we work specifically on these problems, and it's not that we eradicate, you know, a typical Driver -- my wife is leaving me. My wife is leaving me and I have intrusive thoughts from combat and Iraq. We're not necessarily gonna get the wife not to leave. We can try or we might have do some grief work about the loss of that relationship. We aren't necessarily going to reduce PTSD in a matter of six or eight sessions, but we can start (incoherent) exposure or EMDR or whatever intervention that you prefer. And in CAMS, what we do is we shift their relationship to suicide just enough where they see that they've got some alternatives and they don't have to kill themselves to get their needs met.
Dr. Keith Sutton: (15:50)
Yeah. There could be some way out of this pain.
Dr. David Jobes: (15:54)
Yeah. And that's really what the meta-analysis finds, is that we're decreasing hopelessness, we're increasing hope. Ideation tends to drop in six or eight sessions, overall symptom distress is going down, and the patients finding a way of getting their needs met differently, and can move on. And so that's the gist of the CAMS intervention. And it sits among a handful of other interventions that have been proven to work in randomized control trials that most clinicians have no idea about.
Dr. Keith Sutton: (16:26)
Yeah. No, it's yeah. I don't think that these things are brought up or covered or really in the forefront, a lot of focus on safety planning. And I think there's even some old thinking around suicide contracts and having the client actually contract to not harm themselves or kill themselves
Dr. David Jobes: (16:43)
Which never made sense and did not work.
Dr. Keith Sutton: (16:46)
Yeah. Yeah. And it not working, then the person just went more underground rather than really talking about it.
Dr. David Jobes: (16:54)
But that's a great example because back in the day, when I was using no harm contracts, I did it because it was the standard of care made no sense, it's invalidating, it's coercive, it's controlling. And if you don't sign my no harm contract, you're gonna go to the hospital. And as we're gonna talk about hospitalizations are probably more (incoherent) than they are helpful. So we really need to think differently about the way a lot of us were raised.
Dr. Keith Sutton: (17:18)
Yeah. It's something. I was actually in a workshop I was teaching the other day just around kind of the stance of therapy and collaboration that, you know, part of collaboration is having respect for the other person's individual choices. And also, and of course, therapists can get very scared when they're is talking about suicide fidelity, then may view something, say coercive, trying to say, well, I need you to contract to not do this or so on rather than kind of, you know, having the boundaries and saying like, gosh, I, you know, would really like to keep you alive and let's create these changes, but, but still kind of knowing where the therapist ends when the client begins, and the client is gonna make their own choices that they might make, we might need to step in, and sometimes yeah. Hospitalize or something like that. But also that not trying to kind of take over for them.
Dr. David Jobes: (18:05)
The pillars of CAMS are empathy, collaboration, transparency, and honesty, and being suicide focused. So we talk about that kind of thing. Very openly. So I might say to you, Keith, you know, as a provider here in Washington, DC, if you're in clear and in danger, I may have to have you go to the hospital, even whether you want to or not. And I'd rather have to do that. Here's the law and I'll hand them a copy of the DC mental health act with a section about clearing imminent danger highlighted. So they can see exactly what I'm required by my duty as the licensed provider to comply with, so we do that so that the client then knows what they're getting themselves into. And to me, it's like giving up the playbook, you know, it's like putting my cars in the table face up because I want you to know what the implications are of what you're describing.
Dr. David Jobes: (19:02)
And if we both don't want you to go to the hospital, then let's do a thoughtful stabilization plan. Let's get the firearm secured and out of the home. And let's pursue this treatment that's designed to save your life. Why wouldn't you wanna do that? Yeah. And so there's a, you know, a fair amount of motivational interviewing a little paradoxical work. But it tends to be something that, that the patients that we see, they, like we've got data that they like it more than usual care. And we're are trying to keep somebody outta the hospital, which usually is a goal that many patients have some don't and that's a different kind of patient.
Dr. Keith Sutton: (19:38)
I was gonna say that transparency, I think, is so important because sometimes people are reticent to talk about things, you know, even just having some thoughts because they're worried they're gonna get hospitalized. So yeah, I always use that too, of being very, kind of clear about like what would lead to hospitalization or not so that ultimately they can make the choice of what they wanna say or not say and not get surprised, but also kind of it even opens up for sharing more once they know kind of where the lines are of what may trigger, me needing to take action.
Dr. David Jobes: (20:10)
Yeah. Two thoughts on that. One is that back in the day, when I was working as a psych tech and an inpatient unit, people are hospitalized for months and months and months, you know, regularly. Now people are hospitalized for about five or six days and some are hospitalized for two or three days. And they're not getting really any treatment outside of medication, and medication doesn't help much with suicide at risk. So that's point one, point two is that, you know, really with this kind of transparency, and discussion, we're creating, sort of a dynamic in which the patient's view of things is validated without signing off and saying, yeah, you should go kill yourself. And a lot of patients then feel empowered to be a part of the treatment. And so, to me, you give up the illusion of power over this person,
Dr. David Jobes: (21:05)
But you gain credible influence and credibility. And you're side stepping the whole power struggle about whether you can or can't kill yourself. And then what I'm sort of known for, or infamous for saying is that, you know, "You can kill yourself later," but you can't kill yourself while in the treatment because it blows the treatment. Or a little reverence from DBT. Then I'll also say, you know, and why wouldn't you give this treatment a run because you can kill yourself later. Which is true. And so that kind of thinking or that kind of way of talking about we know from paper that came up about three years ago. A small but important study of clinicians, working prior practice and patients who didn't tell their therapists, they were suicidal, cause they didn't wanna go to the hospital -- 63%. So somebody is like, "Well, how are we gonna save lives then? If people are afraid to talk about this, and clinicians are afraid to deal with it?" So, that's really the mission, is to get clinicians to think this is not out of your wheelhouse. You can do this work. You don't have to refer them to the real doctors, the psychiatrists who know much less about treating suicidal risk than most psychologists and social workers and licensed professional answers do.
Dr. Keith Sutton: (22:30)
What I think you were talking about too, that aspect of empathy. And I know as I've been training others and I'm sure I've had this in my own experience too, that when this gets brought up, oftentimes the therapist can get very scared and, and will sometimes shift away from more of an empathic kind of connection to like, okay, now we're into protocol. My, and you know, kind of after the person saying like, oh my gosh, my wife's leaving me. And I just want to kill myself and stuff. Instead of saying like, oh my gosh, sounds really painful. They go into, oh, you wanna kill yourself? Like how long have you been thinking about this? And kind of almost shifting in the mood, which, you know, again, can oftentimes, you know, feel like the client is feeling dropped by the therapist, cause it's no longer validating.
Dr. David Jobes: (23:15)
That's because the client's being dropped by the therapist. They're they're being gotten rid of. And they sense that because you're thinking about where can I get a bed for two or three days. And then they go to the hospital for two or three days and they get started on medication. And some of these meds don't work for a number of weeks, and their life has been significantly disrupted and they sat through a couple groups that they don't find very helpful and they've watched a lot of TV and then they get discharged, and what exactly have we done for them? And the fact is that around the world, there's replicated evidence that, even a single hospitalization, but ultimately any hospitalization the week to two weeks, the four weeks up to six months to a year after that hospitalization, there's a significant increase in risk.
Dr. David Jobes: (24:02)
So there's a psychiatrist in Melbourne, Australia who talks about nosocomial suicides, which are suicides caused, he argues, by the hospitalization, so he's not popular in the psychiatric community, but yeah, it does go to a, you know, a strong view that Marsha Lenahan had, which is that hospitalization is virtually never helpful unless somebody's acutely psychotic. And so my goal is not to bash hospitalization. Maybe some of your podcast, you know folks are on working in patient care. My concern is hospitalization that doesn't have suicide focused intervention. We have a clinical trial right now at the Cleveland Clinic and Mass General Hospital where older teens and young adults are being hospitalized at MGH and Cleveland Clinic. And while they're on the inpatient unit, they're getting up to six IV doses of ketamine. So low dose IV dose of ketamine.
Dr. David Jobes: (24:54)
And when it works, it's pretty extraordinary and it works. I'm not a big fan of medication, but ketamine for some people is really, powerful. They start camps. So the trial is 140 of these pretty seriously suicidal people on an inpatient unit who are either getting cams. I'm sorry. They're either getting ketamine or saline. And the saline is control but everybody's getting cams. One session before they leave and up to eight sessions, post discharge done on tele-health because that high risk post discharge period is really concerning. So now for that hospitalization, you've gotten a medication that maybe facilitates this evidence based intervention that gets started in the inpatient unit and is then traverses the high risk post discharge period. That to me is a good hospitalization.
Dr. Keith Sutton: (25:49)
And have the findings been kind of completed or is it in process currently?
Dr. David Jobes: (25:54)
We just started, yeah. You know, I think about Walter Reed, you know, which is just over here in Bethesda, you know, Walter Reed had a program that Marjan Holloway developed for a five or six day stay where you're getting the Cognitive Therapy for Suicide Prevention Intervention developed by Erin Bed Brown. So for your five or six days stay, you're actually getting a treatment that's been proven to work. And by discharge, oh, you have something that you didn't know, before you were admitted. So this is the way hospitalization should be, but my argument is there's a lot of people that are hospitalized out of clinician, fear and anxiety, mostly about (incoherent) and just not wanting to have somebody kill themselves malpractice and somebody dying. That could be easily inappropriately and better handled on an outpatient basis.
Dr. Keith Sutton: (26:38)
Yeah. I mean, I think that's a good question too about, you know, I think that's something I always struggle with When there's a situation where I'm worried about, should I hospitalize or not, and of course, going through all the, you know, aspects, but you know, sometimes there is a place where it feels like, gosh, I don't know if this person's gonna be safe. They're not necessarily saying I'm gonna do it. Or they're saying there's a high likelihood, you know, it would be clear-cut. If they're saying, oh, I'm gonna go home tonight and you know, do this and to take my own life then of course it's like, yeah, no brainer. Like we need to go for hospitalization. But when they're like, mm, I don't feel like living, but I don't know. I don't know what I'm gonna do. They have a plan or thought of something that actually sounds, possible. And as the clinician trying to figure out like, you know, yeah. What, is the best way to go about this? Do you have any like guidance or thoughts on those kind of ambiguous situations where it's not so clean cut?
Dr. David Jobes: (27:36)
I mean, I'm not very objective, I've used CAMS because you use CAMS, you've at least ensured that the environment has been made safer. That lethal means have been secure. They have a stabilization plan. They'll probably have a crisis support plan with somebody significant in their life. Um, you'll have a sense. Are, are they able to work on their drivers? Are you making therapy attraction? Um, or are they really dysregulated and feeling really shaky last time I pass by somebody's 20 years ago. You know, I just don't do it. And it's not like I have a huge caseload, you know, not compared to somebody like you, but I do have a handful of patients. I do see high risk patients. And I just hardly ever hospitalize somebody because I find there's a way that we can talk about it.
Dr. David Jobes: (28:20)
very candidly. Very appropriately within the guideline of our duty as licensed providers, where hospitalization would really be the absolute last ditch thing that I would ever do. And last time I came close, it was probably 10 years ago. So I, you know, I think about a study Keith, that we did at university of Nevada Reno in the counseling center and the study was looking at cams and dialectical behavior. So it was a clinical trial. It was funded by NIMH. And we saw 62 students, some of whom are very suicidal not a single hospitalization. Meanwhile, I'm consulting to George Washington university hospital. Here in BC and they would hospitalize somebody on the recommendation of a resident advisor. They hospitalized kids left and right. Anybody who whispered suicide boom in a hospital, and I'm working at both these counseling centers and saying, you know, what is this, you know, two very different cultures. One obsessed with litigation. And, you know, they're just on the road from the White House. So they're kind of high profile university, but they are mostly in a CYA fear-of-litigation mode and another counseling center. That's using evidence-based interventions where not a single student was hospitalized.
Dr. Keith Sutton: (29:39)
Wow.
Dr. David Jobes: (29:40)
So that's my point of comparison.
Dr. Keith Sutton: (29:43)
Yeah. I mean, I always kind of, you know, I've had a couple clients over time, you know, where sometimes, you know, we've got the safety plan, but they're like, "I don't know if I would call them. I don't know if I would use these things. Like, I'm just feeling so bad. Like I don't wanna live," and it almost kind of shut down. I think that for me has been the scariest kind a situation, where they're kind of, they can't, they don't know if they can keep themselves safe. They're kind of feeling unwilling to engage in any of the tools or so on. And, you know, sometimes first of my clients, I kind of use a metaphor that, you know, I think about like the flu sometimes, like when you've got the flu, like, you feel horrible, you feel like you're never gonna feel good again, you can't remember feeling, you know, when you were healthy before, but eventually as things get better. You don't quite realize. So I kind of hold the hope for my clients, even if they don't have it, but oftentimes too sometimes that they're just kind of in the shutdown place, which I know for myself, it's been scary and kind of questioning hospitalization, or kind of looking at when there's maybe not the engagement, or they're just so overwhelmed they kind of shut down.
Dr. David Jobes: (30:48)
Well, I think if you are transparent about it, all you say, you know, really my options are limited. And we may have you go to the hospital. It's not my preference, but you know how the law works, and I can't break the law and I feel like you're venturing into imminent, you know, risk. But I feel like clinicians go right to that. And think of it as their first response versus the absolute last ditch, nothing else is gonna, you know, potentially save this life. And that's the thing I think we're talking about here. I'm not saying never hospitalized, but I'm saying, why are you hospitalizing? And what's gonna be the outcome? Is it gonna be better for this person? It may well be better, but a lot of times it makes things worse.
Dr. Keith Sutton: (31:33)
Yeah. It's not really gonna do much except maybe get them through the next few days is the way, I guess I think about it. You know.
Dr. David Jobes: (31:40)
I had a patient, here's a story. I had a patient who overdosed went to group, told the group, she just overdosed. The therapist called me. I went over and picked her up in my car, drove over to a major hospital in the Washington D.C. area, sat with her in the emergency department until two in the morning, she was admitted. I got a call from the social worker, 11 o'clock the next morning saying they were ready to discharge her. She met with her psychiatrist for 20 minutes. Who said to her, next time you feel like overdosing your medication just don't do it.
Dr. Keith Sutton: (32:15)
Oh boy.
Dr. David Jobes: (32:16)
She said, okay. And you wrote up her discharge orders. This is a board-certified attending psychiatrist at a major hospital in Washington D.C. And that was probably 18 years ago. So, you know, you just know it's actually more than that. It's about 25 years ago. So, you know, things have not necessarily evolved from there, getting better. And so I, you know, I don't mean to be radical or provocative, but I do mean to have people think about what's the goal and what's in the patient's best interest.
Dr. Keith Sutton: (32:51)
Well, and even kind of sitting in that place of discomfort before jumping to get to the other side of just saying, okay. Hospital lies, but trying to take the time to understand and look at all the aspects or so on. I think, cause kind of you're saying that some people might be just jumping right to that. And again, it's not like the hospital is gonna be some magic fix
Dr. David Jobes: (33:11)
And well, I think we think it is. And I think that we think that medication's gonna help more than does, it doesn't really help that much. It may help with depression, it may help with psychosis. Now I would not have a patient be referred for medication but the evidence on the SRIs is very mixed. Clozapine is the only medication that's been approved by the FDA for an anti-suicide agent, an atypical antipsychotic and not widely used one RCT, no replication cancer replicated five times in RCTs, and nobody's ever heard of it. So, we have a bias to think that medicine's more effective than it is for suicide risk than it is. And that something magical must happen in the hospital.
Dr. Keith Sutton: (33:52)
Yeah. Like there's some pill, right. That's gonna gonna fix it. And you know, if there was, we would've gotten that, you know, way ahead of time, or oftentimes with the clients that are suffering. I think too, that another detriment is also about, you know, I've talked to some clients about maybe doing an intensive outpatient or doing an inpatient 30 day program or something like that. And I had one client recently and he said like, oh no, I did that before. And then when I explored it, he had been hospitalized for 48 hours or 72 hour hold. And so he was like not interested in going into any more intensive treatment. So I had to do some education around how there's some differences around that. You know, significant differences in what that looks like, because that negative experience led him to be kind of resistant to more intensive treatment.
Dr. David Jobes: (34:41)
Yeah. I'm talking to a guy in Ohio who's, I think he's a LPC, but he's got a business mind, and he's inherently trained to dialectical behavior therapy into CAMS, and we've been talking very seriously about developing clinics where the clinicians would be trained up in DBT in CAMS, and CAMS would have all the ideation because it's the best treatment for ideation and DBT handles all the behavior and that's all they would see. And as akin to in Denmark, they have different regions of the country and every region has a suicide intervention center. And if you're a dangerous citizen, you get 12 sessions of suicide specific care, as a citizen of Denmark. And at the national population level, there's been research showing that's an effective intervention. So, you know, that model is to avert emergency department visits, hospital stays, or people coming out of the hospital, and this guy's convinced that he can actually make this be an effective clinic and franchise it and sort of propagate it. I think it's so much more cost effective than hospitalization.
Dr. Keith Sutton: (35:52)
Yeah Definitely. No, I was wondering too, I don't know if you're familiar. One of the earlier interviews, for this podcast, I also interviewed a Guy Diamond attachment-based family therapy for depressed adolescents and his work with suicide. And I was just, you know, that part of the idea is that by kind of helping to shore up the attachment figures, particularly with these adolescents and their parents, you know, will that is been found a decreased anxiety, depression and so on. Yeah, I was wondering on your thoughts about kind of, yeah that social connection, or the family work or so on in these situations where you've particularly got adolescents or such, or even yeah. These college students.
Dr. David Jobes: (36:32)
Yeah. I'm a big fan of, of Guy Diamond, and of attachment-based family therapy. You know, what I think is, well, what I know is that we did a clinical trial with the us military infantry soldiers at Fort Stewart and Georgia and the soldiers in CAMS. If they had a significant other, a girlfriend or boyfriend, you know, a spouse, we would have them come in. And they would oftentimes, you know, sit and learn about the drivers and learn about the stabilization plan. And so, as you bring 'em back, and one of the things that we found after that trial was that married soldiers did better in CAMS, increased resiliency in overall symptom distress, more than treatment as usual treatment as usual never brought in a spouse. So now we do it all the time. We've got two new funded and IMH studies there with teenagers, and there's a crisis support plan idea that was developed by Craig Bryan, who's at Ohio state, and we now are having all the kids get a crisis support plan by a parent, our grandparent, or significant another, so that they can support the treatment that the kids are actually quite amenable to.
Dr. Keith Sutton: (37:43)
Yeah. Yeah. Well, and oftentimes too, when they have somebody, they don't feel alone, you know, and if they're only seeing the therapist maybe once a week or something like that, at least they have some other supports in between. That's great. And I'm wondering too, you know, I think the tough thing, so I think I shared a little bit with you when we talked on the phone about setting up this interview. Recently, I had a colleague who, took his own life, who passed away. He unfortunately, you know, suffered from bipolar disorder, which, we're pretty sure which had a later onset in his life. And it was unfortunate, I mean, they had, his family had tried to hospitalize. Somebody knew what to say. He had even been to therapy the day before and so on.
Dr. Keith Sutton: (38:29)
And so, you know, and I think that that's one of the scariest things too, because it was very unlike the person. So, you know, I think that, you know, he wasn't himself from what the people had been around him in a few weeks or so on. So that kind of our mind turning against ourselves is so scary. But I mean, there was, I guess, a determination there, around, you know, ending it and despite the interventions that we're trying to be used, or even, you know, again, knowing what to say to the hospitals. I just was wondering about your thoughts on that, that despite all interventions, that sometimes people do make that decision. And, I don't know.
Dr. David Jobes: (39:08)
Yeah. I think the majority of people that take their lives don't do that, but a subset of course, do. You know, they're not dropping hints. They're not in a place where they're being rescued. They don't mess around with pills or razor s. They get a gun or they hang themselves, or they jump over seven stories. You know, so they do a lethal method and they're not rescuable and they don't, and they aren't interrupted. Years ago, I lost a colleague at my university. Literally my friend and colleague across the hall, who's a professor in our department. And, you know, in hindsight, you know, there were little things that I could have thought, oh yeah, that wasn't great. I kind of wish I would talk to him as he hung by my door there that one day.
Dr. David Jobes: (39:56)
Yeah, but it was really something that mostly was not, you didn't see coming from a mile away those happen, but the majority, I would say, especially people who are talking to a therapist, you know, are not out of the blue. And this is a contentious topic among ologists. Are there, is there such a thing as a sudden suicide where there isn't sort of this gradual sort of ramping up an attempt or completion behavior. I did a webinar last week with Craig Bryan and Craig was saying, he thinks in the research they do with, ecological momentary assessment, but there's a small subset of people who start the behavior and then sort of realize that they're taking their life. And he said it was akin to being on a balance beam and your arms start to move.
Dr. David Jobes: (40:50)
And all of a sudden you're starting to go and like, and then you realize you're falling. And so I'm thinking, hmm, that's really interesting. Thomas Joiner would say, there's no such thing as an impulsive suicide. Somebody has thought about in the past and put on a shelf, gets in a situation where they are suddenly dysregulated upset, agitated. They reach for it. Boom. I might argue that this ramping up actually can be compressed in a matter of minutes. But by the end of today, Keith, 130 Americans will have taken their lives, and a hundred percent of them will have suicidal thoughts. If they don't, they're certified as accidents. So the ideation, as I was alluding to early on is such an important thing for us to understand differently and better. And the complexities and nuances of it.
Dr. David Jobes: (41:41)
There are some people who idea at very high levels. This is the ecological momentary assessment data. Where people get beeped on their cell phones or, you know, on their Fitbits and they'll get a lot of data. And so people have very high levels and they'll have a good day and they have a drop, and then SIM has sort of low grade ideation and they have a really crappy day and they spike, and then there are people who are all over the place. Exhausted because they're being thrown around, you know, from suicidal, not suicidal, just regulated, upset, calming down. And that's the kind of resource that we're interested in doing is to really start to understand some of those patterns.
Dr. Keith Sutton: (42:24)
Nuances of that. I was really struck by, I recently did a complex PTSD certification with Janina Fisher online. And you know, in her talking about with complex trauma that oftentimes many individuals who have experienced this, you know, ideation was that way to cope. And, you know, when they were in this helpless stuck situation, particularly if it was childhood trauma, and kind of understanding from the clinician's viewpoint, the function of the ideation and how it's helping, or even if we look into structural dissociation and kind of parts work, as actually just my session before this working with a client, just she was walking down the street and she had to move outta the way cause of somebody and the thought came into her head like, oh, you should just kill yourself. And, you know, we were just looking at that part and then she starts beating herself up for having that thought, but this is a part and she struggles with trauma and throughout, but it's just this, you know, you don't deserve live or burden or whatever it might be. And it just pops in, but she's not actively suicidal or wanting to, but if she's oftentimes thinking about it several times a day. And so it's just part of her life and it doesn't feel good and that's part of the treatment. But I think that was just something significant as I thought about and hearing about just that this is sometimes part of the person's experience rather than, you know, again, that red alert, which again, still needs to be taken seriously and assessed.
Dr. David Jobes: (43:54)
Yeah, but you didn't hospitalize her. You let her mentalize around it and think about it and look at it and understand it. And this, the idea of the functional utility that you learn in the trauma training is absolutely on the money. So that we, you know, we don't rip this away from somebody before they're ready to let go of it. How is that helping them? And for some people, this is like a warm blanket. You know, that it comfort them. It gives 'em a sense of control. They feel empowered. Other people react strongly. What's not to like about that in a certain kind of psychological sense. If we understand that and don't rip that blanket away from them, then they're in a place to kinda listen about alternatives. And that's really how I think about CAMS, or about good psychotherapy, is that we don't react purely outta counter transference. You know, we listen to the functional utility of the words and what it means to this person. And then we pose, you know, sort dangle the carrot of like, well, what would it look like to, to do this? And, and, you know, if we can tolerate that and meta communicate. You're not frightening me. You know, this is a scary topic. But I will be with you in the struggle. And that, that goes so far for the person that struggles with suicide, because they're so expecting to be gotten rid of. When I was younger, I worked with the psychoanalyst named, Maltsberger very famous guy in the field.
Dr. David Jobes: (45:34)
He's like a pioneer. And he was the pioneer that wrote this sort of wildly provocative paper, like in 1978 or something like that, about Contra transference hate in the patient. And archive general psychiatry. It was hugely controversial, so I got to write this book chapter with him and he was one of my heroes and, and we wrote about the therapist Voer. You know, very professional on the outside looking in. Oh, you're really struggling. And there aren't you. You know, but not really engaged. Because of their empathic dread. And so we, then we champion this idea of the therapist participant, with empathic fortitude who would go into that space and people be like, yeah, no. It's too upsetting. I'm just gonna in the hospital. So that's when I looked on it now at 63, and think back over the last 30, some odd years, you know, that's part of CAMS was to kind of back the clinician quite literally to sit next to the patient and use an assessment tool to objectify the suicide risk and start to mentalize. And deconstruct what means for them to be suicidal to then hit the pause button and look at alternative ways of coping, and then treating the things that they say, make them wanna kill themselves. And so because in (incoherent) fortitude really kind of bounced off people's in one ear or not the other. CAMS got us in a place where we were able to say, let's take a seat next to the patient with their permission or online. And we'll pull up the SSF and you tell me what it's like to be you, so I can see it just like you do. I'm a rorschach-er from way back.
Dr. Keith Sutton: (47:27)
Understand your experience. Yeah. Well, and it, the way I think about it too, is that, um, you know, James Kim, who I've worked within our family therapy approach, talked about the hard side and the soft side of hierarchy and kind of, this from strategic family therapy kind of background, you know, for parents, hard side rules, consequences structure, soft side, you know, who students whom who's in charge of good things good times, but also who can handle the hottest topics and to truly kind of have that, that benevolent authority or that positive attachment that we, as the therapist need to be able to handle the hottest topics and be able to stay present with our client, with what they're bringing in. And I forget, I think it was an article. I learned one of my practicums of the term psyche that kind of internal, emotional pain. And as you're talking about with the empathy that, you know, I think of Brown's little video on empathy that, you know, to truly empathize, we have to connect with that part of ourselves that has felt the way the other person has. And if we're connecting with that psyche ourselves, then that can become disregulating and then the person just wants to fix it or like hospitalized or whatever, cause it's, it's too overwhelming and they can't handle the hottest topic in those moments.
Dr. David Jobes: (48:41)
Well, that's exactly right. And then what people will say is like, well I from an ethical standpoint, I don't feel comfortable working with this cause I don't have the expertise. And you know, okay. Then get the expertise. You know, cause to me, it's akin to a primary care provider saying, "Keith, I'll give you a full physical, but you know, I just, I don't do the heart thing. Cardiac, you know, disease just isn't my wheelhouse. So you'll have to see a cardiologist for that." I don't think we can defend saying that we don't handle suicide risk, it doesn't mean that you have to become an expert. But at a minimum you can learn about safety planning. Or the national lifeline, or the national text line, you can learn about lethal means safety discussions and how to secure firearms and how to secure, you know, stashes of pills. Work out forbid you can learn intervene like CAMS or BCBT or CTSP or DBT. And you know, really be a part of the solution.
Dr. Keith Sutton: (49:42)
Well, I think it's so important to the model that you've got, because I think that the other aspect is the clinician feeling competent and needing to have that competent. Cause if they're not feeling competent, it feels out of control. It feels scary. They don't have a roadmap. They don't know where they are or where they're going. So, yeah, it's great. You know, I love the measure to kind of assess and plan and I I'm really looking forward to learning more about this treatment approach cause I think it's definitely something that's needed and something that's neglected because suicide and suicidal ideation is like, you're saying you can't avoid it in treatment in your work with clients. So you need to know how to learn it and, it would be, you know, kind of neglectful to say, well, I just don't do that. Because it's gonna come up, whether you screen for it or not.
Dr. David Jobes: (50:29)
Well, and ironically, most of us aren't trained. I mean, across mental health disciplines. Less than 30% have even an hour on the assessment treatment of suicide risk in graduate school, professional training programs. So I'm not pointing fingers and looking down my knows, I'm saying, yeah, we've got a problem. It's a training problem. I love training young people and clinicians in graduate school because they don't have attitude, they're scared, they wanna get it right. And they believe in evidence-based practices. And they can become expert in our intervention in lickity split.
Dr. Keith Sutton: (51:05)
They wanna know what to do, they want direction and some guidance and structure to it. Well, thank you so much for your time today. I really appreciate it. This is such an important topic and you know, yeah. I'm looking forward to learning more about your work and I'll link to your information on our website for folks that are interested, learning more, I'm sure we're doing trainings or workshops or things like that. I really appreciate it. Thank you for taking the time.
Dr. David Jobes: (51:34)
Thanks Keith. I appreciate being on the podcast and hope to see you again some time.
Dr. Keith Sutton: (51:38)
Okay, great. Take care. Bye-bye bye.
Dr. Keith Sutton: (51:42)
Thank you for joining us. If you're wanting to use this podcast or continuing education credits, please go to our [email protected]. Our podcast is brought to you by the Institute for the advancement of psychotherapy, providing in person and remote therapy in the San Francisco Bay Area. IAP provides screening for licensed clinicians through our in-person and online programs, as well as our treatment for children, adolescents, families, couples, and individual adult. For more information, go to sfiap.com or call 4 1 5 6 1 7 5 9 3 2. Also, we really appreciate feedback. And if you have something you're interested in, something that's on the cutting edge of the field of therapy, and think clinicians should know about it, send us an email or call us we're always looking for the advancements in the field of psychotherapy to help in creating lasting changes for our clients.