David Jobes Addresses NJ-ACT on Suicide

By Lynn Mollick

On Sunday, December 10, Dr. David A. Jobes presented a NJ-ACT workshop entitled “Suicide: Empirically Supported Assessment and Treatment.” After 30 years of work as a psychologist studying suicide, Dr. Jobes has concluded that traditional treatment methods do not work:

1. Hospitalization increases the risk of suicide immediately post-hospitalization and probably in the long term as well.
2. Medication is of questionable benefit in reducing suicide risk.
3. Treating depression without addressing suicide will not reduce risk.

Dr. Jobes’ research has demonstrated that suicide-focused psychological treatment can keep patients alive and out of the hospital until the suicidal crisis has passed.

Assess Suicide Risk
Assessment is the first step. Discussing suicide openly reduces the likelihood that patients will make an attempt. Frank discussion of the topic demonstrates your willingness to understand patients’ motivations for suicide and does not cause patients to become more suicidal.

Objective measurement of suicide risk is more reliable than clinical judgment. Several well-established tools are in the public domain:

1. The Columbia Suicide Severity Rating Scale
2. Reasons for Living Scale (Linehan) — online calculator. Answers can be printed out or transferred to an electronic medical record.
3. PHQ-9 — assesses depression (last question pertains to suicide)

Aaron Beck noted that patients are ambivalent about dying. Dr. Jobes suggested estimating ambivalence by subtracting the wish to die from the wish to live (perhaps on a 7-point scale). Knowing suicide risk helps you determine the intensity of treatment required. Factors that indicate increase suicide risk include:
1) Prior attempts
2) Extensive planning or rehearsal of a suicide plan
3) Repeated rumination on the same content
4) Taking steps to implement a plan

Develop a Safety Plan
Suicidal crises are usually brief – a few seconds to a few hours – and it is important for patients to have a written plan.
1. Identify warning signs that will trigger use of the safety plan
2. List specific internal and external strategies patients can employ on their own (e.g. prayer, taking a walk or warm bath, watching a movie)
3. Identify friends, family, agencies, professionals who might be helpful, and very importantly,
4. Very important: Make the environment safe by removing weapons, unnecessary medication, etc.

Psychological Treatments That Reduce Suicide Risk
1. DBT with all four components – individual, group, between session therapist contact, and therapist consultation group. DBT chain analysis is especially helpful because it teaches patients to identify antecedents and consequences of suicidal behavior patterns and then helps patients plan alternate behaviors.
2. Suicide-focused CBT
3. Construction of a “Hope Box” filled with items reminding the patient that their life is worth living.
4. A Virtual Hope Box app
5. A written safety plan.

Collaborative Assessment & Management of Suicide (CAMS)
CAMS is Dr. Jobes’ approach to treating suicidal patients. It is an outpatient program, structured but not manualized, useful for clinicians of all theoretical orientations, and applicable across cultures. Twelve studies support CAMS’ effectiveness. Collaboration between therapist and patient is essential throughout, and therapists must express empathy to demonstrate understanding of patients’ wish to die.

Every session begins with completion of the Suicide Status Form (SSF) available in Dr. Jobes’ workbook Managing Suicidal Risk: A Collaborative Approach (Guilford Press). Patients make 1 to 5 ratings of their psychological pain, stress, agitation, hopelessness, self-hate, and overall suicidality. The SSF asks patients to list their reasons for living and reasons for dying. It also asks “what one thing would help me no longer feel suicidal?”

Chain analysis and the SSF help patients understand the situations, thoughts, feelings and behaviors that precipitate suicidal ideation. Any treatment modality can then be used to address the factors that drive suicidal ideation. A “stabilization plan” identifies what patients will do to make their lives better. Treatment of suicidal patients should always be focused on suicidality. An overview of the CAMS
Treatment Manual is here.

“No Suicide” Plans and Suicide Blackmail
Dr. Jobes advised against “no suicide plans” because they create a power struggle between therapist and patient. Instead, he recommends acknowledging patients’ right to take their own lives, but suggest that therapist and patient collaborate for a period of 3 to 4 months to relieve patients’ hopelessness. To collaborate in CAMS treatment patients must:
1) Be willing to remove or decrease access to means for suicide
2) Attend sessions regularly
3) Work with the therapist on therapeutic goals and barriers to improvement
4) Be willing to increase social support

If patients are not willing to collaborate in this way, therapists risk “suicide blackmail,” where therapists violate their usual practices, for example, by providing too many appointments or too much between session contact. This will cause therapists to experience undue worry and helplessness. Instead, Dr. Jobes advises therapists to recommend another treatment modality or a break from treatment.

Managing Clinicians’ Malpractice Exposure
To limit liability, Dr. Jobes recommended:
1) Assess suicide risk using objective measures.
2) Treat risk factors appropriately, e.g. by contracting with the patient to remove lethal means, developing a safety plan.
3) Follow up on risks and modify the treatment plan as treatment progresses.
4) Keep complete and meticulous records.