Understanding Therapists’ Work With Suicidal Patients: An Examination of Qualitative Data

Abstract

The collaborative assessment and management of suicidality (CAMS) serves as a framework for maintaining a collaborative relationship between the therapist and patient. This study used an original coding manual to examine responses to open-ended questions to better understand the ways in which therapists use CAMS collaboratively as well as their reasons for adhering (or not adhering) to certain aspects of the framework. Results suggest differences in treatment application based on therapist characteristics including amount of experience, intensity of training received, and experience of a patient suicide attempt. Implications of this research include informing therapists interested in using the CAMS framework about the specific ways in which implementation can be made collaborative. Further, this research helps to shed light on how experiencing a client’s death by suicide can impact therapists’ future work with suicidal clients.

Keywords

suicide suicide prevention counseling therapy qualitative research

The continually rising rate of deaths by suicide in the United States each year (Centers for Disease Control and Prevention, 2016) has made uncovering the most efficacious therapeutic interventions for treating suicidal ideation a gravely important task. The current standard of care for those presenting an imminent risk of suicide has been to hospitalize the patient until he or she has safely reached a state of stabilization where self-harm is not a primary concern (Bongar, 2002; Granello, 2010; Jobes, 2017). While extreme cases may warrant hospitalization, some in the field argue that this is not the best course of action for someone who is suicidal due to increased risk of suicide and self-harm risk posthospitalization (Deisenhammer, Huber, Kemmler, Weiss, & Hinterhuber, 2007; Ho, 2003; Jobes, 2017; Kan, Ho, Dong, & Dunn, 2007; National Institutes of Health, 1999). Perhaps contributing to this vulnerability, another major concern with hospitalization is that the mean length of stay for a suicidal individual has been reported as short as 2.7 days (Olfson, Gameroff, Marcus, Greenberg, & Shaffer, 2005). This transient hospitalization is likely an insufficient amount of time to effectively reduce the individual’s future vulnerability to suicidal ideation and subsequent suicidal behavior.

Consequently, some mental health professionals advocate for replacing hospitalization with long-term outpatient, specialized care for those experiencing persistent thoughts of suicide (Britton, Williams, & Conner, 2008). While there still remains a dearth of empirically supported interventions for treating suicidal individuals, cognitive therapy for suicidal patients (Wenzel, Brown, & Beck, 2009), brief cognitive behavioral therapy (Rudd et al., 2015), and dialectical behavior therapy for suicidal patients with borderline personality disorder (Linehan, 1993; Linehan et al., 2006) are three approaches that have shown promising results for effectively reducing suicidal risk. Another approach that has gained empirical support for managing suicidal ideation without relying on hospitalization is the collaborative assessment and management of suicidality (CAMS; Jobes, 2012, 2016, 2017) framework.

CAMS is a therapeutic framework of collaborative clinical assessment, treatment planning, and management of suicidal risk that can be used in conjunction with other interventions (Ellis, 2017; Ellis, Green, Allen, Jobes, & Nadorff, 2012; Jobes, Gregorian, & Colborn, in press). In CAMS-guided practice, suicide the focus of therapy, creating a shared understanding of the patient’s psychological suffering that defines their suicidal ideation. These issues are addressed in the first session of CAMS treatment in which the therapist and patient sit side by side and complete the Suicide Status Form (SSF) together. The SSF is a valid and reliable suicide risk assessment tool that asks patients to rank and describe their psychological pain, stress, agitation, hopelessness, self-hate, and overall behavioral risk of suicide (Conrad et al., 2009; Jobes, Jacoby, Cimbolic, & Hustead, 1997). CAMS treatment planning initially focuses on the CAMS Stabilization plan and the identification of two patient-defined suicidal “drivers” which are the problems that lead to consider suicide (Jobes, 2016).

As described by Jobes, Gregorian, et al. (in press), CAMS is supported by eight correlational or open clinical trials. There are now three published RCTs supporting the use of CAMS as means of quickly eliminating suicidal ideation in six to eight sessions (Comtois et al., 2011; Jobes, Comtois, et al., 2017), reducing overall symptom distress and hopelessness while increasing patient satisfaction and retention to clinical care when compared to treatment as usual (Comtois et al., 2011). There are promising data that CAMS may effectively treat self-harm and suicide attempts (e.g., Andreasson et al., 2016).

Nevertheless, while empirical evidence strongly shows that CAMS helps to reduce suicidal risk in a variety of populations, it is unclear how therapists trained in CAMS are actually using it in their practice, or for those not using it, why they are choosing not to. A multitude of factors could greatly influence how any individual therapist understands and subsequently decides to foster a collaborative relationship as described in CAMS.

To this end, this study examined how therapists’ collaborated with suicidal patients as well as why they were or were not using specific aspects of the CAMS framework. This work stemmed from a previous investigation in which therapists reported their levels of adherence to CAMS (Crowley, 2015). Results of Crowley’s adherence study suggest male therapists and those who had more intensive CAMS training reported a higher level of comfort in using statements with patients who represented the underlying CAMS philosophy. Further, influence of cognitive-behavioral theoretical orientation, years of experience, and age were positively correlated with CAMS adherence.

While Crowley’s (2015) quantitative findings aid in understanding therapist adherence to CAMS, qualitative assessment is essential in fully understanding emerging issues in therapy utilization (Arnkoff, Glass, Elkin, Levy, & Gershefski, 1996; Kazdin, 2008; Lazicki, Vernberg, Roberts, & Benson, 2008). Thus, open-ended questions and coding systems have led to a more thorough understanding of the therapeutic alliance (Constantino, Morrison, MacEwan, & Boswell, 2013), the clinical utility of interventions (Hernandez & Weagraff, 2011; Rose, 2013), and therapist adherence and integration of a newly learned therapy into clinical practice (DiGiorgio, Glass, & Arnkoff, 2010). Accordingly, this study developed a coding manual to categorize therapists’ responses to Crowley’s (2015) open-ended questions. Amalgamating the possible factors associated with clinical decision-making, several hypotheses were proposed: (a) intensity of training, theoretical orientation, and number of years in practice will be significantly related to the types of collaboration used in certain aspects of therapy; (b) intensity of training and theoretical orientation will also be significantly related to the reasons given for not adhering to specific CAMS procedures; and (c) whether therapists had a patient make a suicide attempt while in treatment or underwent more intensive training are predicted to influence reasons for not adhering to certain aspects of CAMS.

Method

Participants

Participants were 120 therapists trained in CAMS who had completed 10 open-ended questions included in Crowley’s (2015) study. A large number (n = 71) attended a more intensive CAMS training (i.e., a 1 day or longer program or an interactive online training), while fewer (n = 49) attended a less intensive training (i.e., a 1–2 hour workshop or read the CAMS book). The sample comprised clinicians who were predominantly Caucasian (86.7%), majority female (66.7%), and had worked in clinical practice for 6 or more years (54%; M = 10.99). Further, the majority of participants had experienced a patient suicide attempt at some point throughout treatment (59%), while a much smaller percentage had experienced a patient death by suicide during treatment (15.8%) or had been sued for malpractice or wrongful death (1.7%). Slightly less than half (47%) had doctoral degrees, 42% had masters degrees, and the rest were bachelors-level or “other.” The most frequent primary work settings were community mental health centers (29%), university counseling centers (19%), outpatient clinics (11%), psychiatric hospitals (10%), and private practice (9%). Over half (n = 65) identified with a primarily behavioral or cognitive-behavioral theoretical orientation, while the rest (n = 52) identified with either psychodynamic or psychoanalytic, humanistic or experiential or existential, systems or family systems, or “other.”

Procedure

In Crowley’s (2015) study, requests for participation were sent via email to members of organizations that recently conducted a CAMS training (n = 943), members of the American Association of Suicidology listserv (n = 637), and members of the Association of Behavioral and Cognitive Therapies’ Suicide and Self-Injury Special Interest Group listserv (n = 143). Included in the requests were information about the study, a statement of confidentiality and voluntary participation, and a survey link. Participants who accessed the online survey were given a more detailed description of the study, its exclusion criteria, and the opportunity to enter a raffle for a $50 gift card after completing the entire survey. The survey was accessed by 195 therapists and 120 who had received CAMS training completed all measures, which took roughly 25 minutes.

Measures

Suicide Training Questionnaire

Four open-ended questions are included on the Suicide Training Questionnaire (STQ) which assessed therapist use or lack of use of CAMS with all suicidal patients. After selecting a preferred suicide-focused intervention or framework for working with patients, a final open-ended question asks why this particular approach was chosen.

Suicide Assessment and Treatment Questionnaire

The Suicide Assessment and Treatment Questionnaire (SATQ) consists of four open-ended questions to determine how therapists make therapeutic processes collaborative, including assessment or exploration of suicidal risk, deconstructing factors that make a patient suicidal (“drivers”), treatment planning, and interventions. A fifth open-ended question asks what therapists do to cultivate a sense of purpose or meaning when working with suicidal patients.

CAMS Application Questionnaire

The final questionnaire includes three open-ended questions to assess reasons for not adhering to CAMS methodology. If the response is “no” to ever sitting next to patients, or using CAMS Tracking or Outcome forms, therapists are then asked to explain specifically why not. A fourth question asks what specific portions of the SSF therapists have their patients complete (e.g., Tracking and Outcome Forms to monitor long-term suicidal risk). The last open-ended question asks therapists to indicate when they would stop using CAMS with a suicidal patient.

Coding System for Open-ended Responses

Therapists’ responses were first unitized and divided into different meaning units based on conceptually distinct ideas (see DiGiorgio et al., 2010; Gershefski, Arnkoff, Glass, & Elkin, 1996). The first author unitized all responses and a master’s student in psychology unitized 10% of the responses, with an overall agreement of 93% (κ = .95). A coding system was then developed for responses to the 10 open-ended questions pertaining to therapist collaborative use and application of CAMS with suicidal patients.

Once the coding manual was finalized, the first author trained the same second rater to use the coding manual by discussing the coding categories for each question and answering questions. After training, both raters practiced coding with additional sample responses for each question and reached a κ criterion of .91. Finally, the first author coded all participant responses to the 14 open-ended questions into the mutually exclusive categories, and the second rater coded 10%. The two coders agreed on categorization of responses 87% of the time (κ = .84).

Research and theoretical models can be applied to justify the coding categories. Specifically, the information processing theory emphasizes cognitive processing and control to incorporate new information into an existing database. Research suggests individual factors such as level of experience (Caspar, 1997; Manias, Aitken, & Dunning, 2004), training received (Beidas & Kendall, 2010), and theoretical orientation (Gyani, Shafran, Myles, & Rose, 2014; Stewart & Chambless, 2007), can greatly impact the decision-making process. Thus, the coding category “reasons related to the therapist” (e.g., theoretical orientation, training background) is reflective of the information processing theory and supporting literature.

The clinical decision-making literature also indicates that therapists can base many decisions on patient reactions, responses, and nonverbal cues (Oddli & Halvorsen, 2014; Rober, Elliott, Buysse, Loots, & De Corte, 2008), supporting the category “reasons related to patients.” Further, empirical studies suggest the setting in which a therapist practices (e.g., private practice, hospital) can influence the interventions used and how clinical decisions are carried out (Gyani et al., 2014; Hartfield & Ogles, 2007), as seen in the coding category “reasons related to the agency or setting.” The coding categories describing methods of collaboration were extracted from common themes emerging from therapies and frameworks used to treat suicidal individuals (i.e., CAMS, CT for suicide prevention, and dialectical behavior therapy).

Results

Responses to several therapist questions were combined for subsequent data analyses. Due to unequal numbers of therapists who chose theoretical orientations, responses were dichotomized as either behavioral or cognitive-behavioral (n = 67) or other (n = 52). CAMS training was defined as more intensive if it involved a 1 day or longer program or an interactive online training (n = 71), and less intensive if it was only a 1 to 2 hour informal workshop or involved reading the book describing CAMS (n = 49). Finally, number of years in practice was divided into three categories; therapists who indicated 0 to 10 years of experience were defined as having been in practice for a shorter amount of time (n = 47), 11 to 20 years of practice was considered moderate (n = 54), and 21 or more years was defined as a longer amount of time in practice (n = 19). Chi-square analyses were used to examine the association between responses coded into each separate category and the appropriate predictor variables. Fisher’s exact test (Preacher & Briggs, 2001) and the Freeman-Halton extension of the test (Lowry, 2014) were used in cases where expected counts were less than five.

Use of CAMS and Other Interventions

Response rates for answers to open-ended questions on the STQ can be found in Table 1. Contrary to expectations, theoretical orientation was not related to any outcome variables on the STQ, including reasons why therapists said they had or had not used CAMS or reasons for selecting their first choice intervention for suicidal patients

Table 1.

Categories, Examples, and Number of Respondents for Reasons for Use of CAMS and Other Interventions.

STQ 7: How many patients have you used CAMS with, throughout your career? If you answered “0,” why haven’t you used CAMS?
STQ 8a: If you have used CAMS, do you use it with all patients for whom suicide is an active concern? If “Yes,” why?
STQ 8b: If you have used CAMS, do you use it with all patients for whom suicide is an active concern? If “No,” why not?
Categories	Examples (7)	Respondents (n), (% of total)
		7	8a	8b
A. Reasons related to the Therapist	I typically use cognitive therapy	9 (8%)	0 (0%)	2 (2%)
B. Reasons related to the Agency/Setting	No on-site CAMS consultation team	1 (1%)	12 (10%)	5 (4%)
C. Reasons related to CAMS	Too much paperwork	3 (3%)	51 (43%)	21 (18%)
STQ # 10: “Which of the following suicide-focused interventions/frameworks would be your first choice to use when working with patients for whom suicide is an active concern?” Why would the intervention/framework you selected be your first choice?
Categories	Examples	Respondents (n), (% of total)
A. Reasons related to the Therapist	I like using this intervention	22 (18%)
B. Reasons related to the Agency/Setting	Agency policy to use it	13 (11%)
C. Reasons related to the Intervention/Framework	Because it is effective	55 (46%)

Note. Coding for all questions also included the categories “D. Other” and “E. No responseiven.” STQ = Suicide Training Questionnaire; CAMS = collaborative assessment and management of suicidality.

Methods of Collaboration

Table 2 shows response rates on the SATQ. Contrary to predictions, therapist theoretical orientation did not yield significant relationships with the collaborative methods used in any components of therapy. However, intensity of CAMS training was found to significantly relate to the methods of collaboration used to cultivate a sense of purpose or meaning when working with suicidal patients. More specifically, those who attended less intensive training were significantly more likely (31.6%) to describe using the SSF or following CAMS protocol (e.g., making a “Reasons for Living” list) to cultivate a sense of purpose or meaning, compared to therapists who attended more intensive training (11.4%), χ²(1, N = 82) = 5.07, p = .02.

Table 2.

Categories, Examples, and Number of Respondents for Methods of Collaboration.

SATQ # 3: What, if anything, do you do to make your assessment/exploration of suicidal risk collaborative?
SATQ # 5: What, if anything, do you do to make the process of deconstructing factors that make a patient suicidal (or, identifying “drivers”) collaborative?
Categories	Examples (#3)	Respondents (n), (% of total)
		#3	#5
A. Interactive exchange	Balancing my suggestions with those from patients	36 (30%)	58 (48%)
B. Expressing empathy	Express an understanding for why the patient wants to die	9 (8%)	4 (3%)
C. Using the SSF/following CAMS protocol	Sit next to patient while completing the SSF	42 (35%)	27 (23%)
SATQ #8: What, if anything, do you do to make your treatment planning with suicidal patients collaborative?
SATQ #27: What, if anything, do you do to make your interventions with suicidal patients collaborative?
Categories	Examples (#8)	Respondents (n), (% of total)
		#8	#27
A. Interactive exchange	Motivational interviewing	51 (43%)	70 (58%)
B. Target patient therapeutic goals/suicidal risk	Focus on goals of therapy	25 (21%)	10 (8%)
C. Using the SSF/following CAMS protocol	Use SSF to develop treatment plan	14 (12%)	8 (7%)
SATQ #29: What, if anything, do you do to cultivate a sense of purpose or meaning when working with suicidal patients?
Categories	Examples	Respondents (n), (% of total)
A. Identify goals or explore values	Encourage volunteer work	56 (47%)
B. Target and enhance patient strengths	Teach patient skills to help work toward their future goals	9 (8%)
C. Using the SSF/following CAMS protocol	Write RFL together	17 (14%)

Note. Coding for all questions also included the categories “D. Other” and “E. No responsegiven.” RFL = Reasons For Living; SATQ = Suicide Assessment and Treatment Questionnaire; SSF = Suicide Status Form; CAMS = collaborative assessment and management of suicidality.

As hypothesized, methods of collaboration used in cultivating a sense of purpose or meaning were also significantly related to the number of years therapists had been in practice. Using the Freeman-Halton extension of Fisher’s exact test (Lowry, 2014), it was found that clinicians with less experience practicing psychotherapy were significantly more likely to report using the SSF or following CAMS protocol (39.4%) to cultivate a sense of purpose or meaning than therapists who had been practicing for a moderate (7.9%) or a longer amount of time (9.1%), p = .004. Conversely, those who had been in practice for a moderate (81.6%) or a longer amount (81.8%) of time were significantly more like to identify goals or explore values to cultivate a sense of purpose or meaning with suicidal patients, than those who had been practicing for a shorter amount of time (48.5%; p = .007.)

Adherence to CAMS Framework

Table 3 shows response rates of open-ended questions on the CAMS Application Questionnaire (CAQ). Again, theoretical orientation was not significantly related to reasons for lack of adherence to any aspects of CAMS, or to the point in time at which CAMS is terminated.

Table 3.

Categories, Examples, and Number of Respondents for Adherence to CAMS Framework.

CAQ 3: In your use of CAMS, is there any point during which you actually sit next to your patients? If “No,” why not?
Categories	Examples	Respondents (n), (% of total)
A. Reasons related to the Therapist	I find it to be uncomfortable	7 (6%)
B. Reasons related to patients	Patients react differently when I do this	2 (2%)
C. Reasons related to the agency/setting	My chair is bolted to the ground and can’t be moved	4 (3%)
CAQ 5: Do you use the CAMS Tracking Forms? If “No,” why not?
CAQ 6: Do you use the CAMS Outcome Forms? If “No,” why not?
Categories	Examples	Respondents (n), (% of total)
		#5	#6
A. Reasons related to the Therapist	I prefer not to use them	7 (6%)	16 (13%)
B. Reasons related to CAMS tracking/ outcome forms	No research suggesting forms improve outcome	7 (6%)	12 (10%)
C. Reasons related to the agency/setting	Don’t have access to forms at my agency	8 (7%)	13 (11%)
CAQ 4: When you typically use the SSF, do you have the patient complete certain portions? If “Yes,” what portions?
Categories	Examples	Respondents (n), (% of total)
A. All of section A	I typically have patients complete the entire first page of the SSF	50 (42%)
B. Part but not all of Section A	Reasons for living/reasons for dying	18 (15%)
CAQ #7: When would you stop using CAMS with a patient with whom you have been using it?
A. Objective, CAMS-directed point in time	After three consecutive sessions with no suicidal risk	28 (24%)
B. Objective, non-CAMS-directed point in time	After 1 month without any suicidal ideation	8 (7%)
C. Subjective point in time	When I think the patient is ready to end CAMS	50 (42%)

Note. Coding for all questions also included the categories “D. Other” and “E. No response given.” CAQ = CAMS Application Questionnaire; SSF = Suicide Status Form; CAMS = collaborative assessment and management of suicidality.

As hypothesized, whether therapists had a patient make a suicide attempt while in treatment was found to be related to reasons for not adhering to certain aspects of CAMS. Specifically, therapists who did not have a patient make a suicide attempt while in treatment were more likely to stop using CAMS after the suggested three consecutive sessions of no reported suicidal ideation (50.0%), as opposed to therapists who did have a patient make a suicide attempt (23.3%), χ² (1, N = 86) = 6.38, p = .01. Conversely, therapists who had a patient make one or more serious suicide attempts while in treatment were significantly more likely to report ending CAMS at a subjective point in time (66.1%) than therapists who did not have a patient make a suicide attempt (43.3%), χ² (1, N = 86) = 4.15, p = .04.

Reasons for not sitting next to patients during CAMS use were found to be significantly related to the type of training received. Specifically, therapist who attended less intensive training were more likely to indicate not sitting next to patients for reasons related to the agency or setting (57.1%) compared to therapists who attended more intensive training (0.0%; p = .03, Fisher’s exact probability test).

Discussion

The main purpose of this study was to understand how therapists collaborate with suicidal individuals within the CAMS framework (as well as why they do or do not decide to use specific aspects of CAMS), and if this is contingent on specific therapist factors. As hypothesized, number of years in practice and intensity of training were significantly related to the methods of collaboration used in certain components of therapy. In addition, intensity of training and having had a patient make one or more suicide attempts while in treatment were found to relate to the point in time at which CAMS is terminated or reasons for not adhering to certain suggested CAMS practices.

Significant differences in CAMS adherence were found based on level of experience. In this study, therapists who had been in practice for a shorter amount of time were more likely to report using the SSF and following CAMS protocol in order to foster a sense of purpose with suicidal patients, whereas therapists who had been in practice for a longer length of time were more likely to describe methods that were classified as identifying goals or exploring values. It has been argued that less-experienced therapists may be more likely to strictly follow techniques of novel treatment approaches or newly learned therapies (Stein & Lambert, 1984; Wogan & Norcross, 1985). Therefore, therapists who have less experience may be more likely to follow CAMS protocol more closely, rely heavily on techniques learned in training and thus collaborate with suicidal patients in ways that reflect CAMS methodology. Conversely, therapists who have been in practice for a longer length of time likely have a wider range of therapeutic skills that they can employ in order to collaboratively work with suicidal patients, as opposed to focusing on methods learned in CAMS training.

Therapists who had received less intensive CAMS training were also significantly more likely to use the SSF and follow CAMS protocol in order to collaboratively cultivate a sense of purpose. While this may initially appear counterintuitive, additional analyses revealed those who had less intensive training were significantly more likely to have practiced psychotherapy for fewer years compared to those who attended more intensive training. Therefore, this finding is likely reflective of the therapists’ inexperience rather than the intensity of training received.

CAMS adherence also differed as a function of intensity of training, which is supported by previous research (e.g., Lyhus, 2003). Participants who attended less intensive training were significantly more likely to not sit next to patients for reasons related to the agency or setting (e.g., “The chairs at my agency are bolted to the floor and will not move.”) This finding could be better explained by the positive relationship between intensity of training and number of years in practice, as described previously. More experienced and established therapists have more opportunity and a greater likelihood of working in private practice settings that would be more flexible. In additional, agencies that adopt and promote CAMS may offer more intensive training. Thus, these factors of the individual therapist (i.e., training and experience) and the environment (i.e., treatment setting) all work in concert with the therapist’s existing knowledge and perceived stimuli to shape the decision of whether or not to sit next to a patient.

The point of time at which therapists choose to discontinue use of CAMS was also found to be significantly related to their experience with patients making suicide attempts. Therapists who had a patient make a suicide attempt were significantly more likely to stop using CAMS at a subjective point in time, whereas therapists who did not have a patient make a suicide attempt were more likely to stop at the CAMS-directed point in time. Research has shown that patient suicide and patient suicide attempts during treatment can have a profound negative impact on the therapists’ well-being, including the development of severe symptoms of stress, guilt, and intrusive thoughts (Kleespies & Dettmer, 2000; McAdams & Foster, 2000). This result could be reflective of the idea that therapists who have not experienced the stress of having had a patient make a suicide attempt may be more comfortable ending suicide tracking at the time indicated in the CAMS manual, whereas therapists who have experienced a client suicide attempt may wish to prolong tracking in order to ascertain a patient’s level of risk.

Having had a patient make a suicide attempt could influence therapist decision-making, such that they are more inclined to act in ways that will minimize further expected risks (e.g., another patient suicide attempt, a patient death by suicide, avoid litigation). In certain cases, this would undoubtedly prove to be the best course of action, ultimately reducing the patient’s risk for suicide. However, it is possible that making certain decisions based on risk aversion could result in dire consequences. For example, some therapists who are apprehensive in treating suicidal patients may choose to admit the patient to a hospital in order to avoid being sued for malpractice (Baerger, 2001; Hoge & Applebaum, 1989; Jobes & Berman, 1993). This hospitalization is unlikely to resolve the patient’s thoughts of suicide (Linehan, 1993; Paris, 2004) and may even increase their risk of dying by suicide (Ho, 2003; National Institutes of Health, 1999). Therefore, this possible bias in risk aversion can sometimes be in conflict with therapeutic goals.

Despite these differences in how therapists collaborate with suicidal patients, theoretical orientation was not found to significantly relate to methods of collaboration in CAMS, which goes against previous research and this study’s hypotheses. However, this could be due to a limitation of the study. Due to the small number of therapists from some orientations other than cognitive-behavioral, humanistic, psychodynamic, and family systems orientations were combined into a single category. Thus, it is possible that because there were not enough participants from various orientations, these differences could not be uncovered. A larger sample of therapists from each theoretical orientation would allow for exploration of differences in how therapists from each of these theoretical orientations collaboratively work with suicidal patients.

Theoretical orientation was additionally not found to be significantly related to reasons for not adhering to CAMS practices, the point of time in which CAMS treatment is ended, or reasons for using CAMS and other interventions. Although this was unexpected, in some ways it is not surprising as CAMS is described as a flexible, transtheoretical approach to treatment (Crowley, 2015; Jobes, 2016). These nonsignificant findings thus support the claim that therapists of any theoretical orientation can use and adhere to the approach.

While this study broke new ground in examining therapists’ open-ended responses describing their adherence and collaborative utilization of CAMS with suicidal patients, it is not without some limitations. Due to a relatively small sample size of mostly Caucasian, female therapists, results may not generalize to more diverse populations of therapists of varying backgrounds. Another limitation of this study stems from the reliance on self-report measures of therapy practice. It is possible that some therapists failed to fully explain how they make certain processes in CAMS collaborative, or that there may have been a demand characteristic to report being adherent to CAMS. In addition, some therapists could have responded in ways that reflect the methods of collaboration used with one or two patients they were treating at the time of taking the survey, rather than describing how they generally collaborate with all suicidal patients.

Despite these limitations, the findings in this study are relevant to therapists interested in working collaboratively with suicidal patients, as well as institutions and persons interested in becoming trained in CAMS via CAMS-care, LLC©. Therapists might want to be aware of the methods of collaboration that they are more or less likely to use based on years of practice and the intensity of training received, so as to possibly incorporate other collaborative methods in their use of CAMS. In addition, it would be helpful for therapists wanting to work collaboratively with suicidal patients know that therapists who had a patient make a suicide attempt could be more likely to stop using a suicide-focused framework at a subjective point in time, rather than at the point suggested in the manual. These differences in collaboration and reasons for not adhering could be helpful in understanding how experiencing a patient’s death by suicide may influence therapists’ work with future suicidal patients.

Future investigations should include a more diverse sample of therapists and observational measures of collaboration. Additional investigations could also utilize outcome measures of patients’ suicidality to understand if certain methods of collaboration are associated with greater reductions in suicidal risk. Further research should also examine if therapists are prolonging CAMS tracking, or other suicide-specific interventions, as a direct result of experiencing a patient making a suicide attempt and attempting to avoid future risks. This information could aid in reducing possible therapist stress, guilt, and overall negative affect associated with patient suicide attempts, as well as increasing therapist confidence to end tracking when no longer needed. In addition, it is imperative for clinicians to be aware of this potential risk aversion bias in order to encourage appropriate clinician decision-making. This study represents an important first step in understanding, in therapists’ own words, how those trained in CAMS implement it in their clinical practice.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Maureen F. Monahan, MA, is a doctoral candidate at the University of South Florida studying suicide prevention. This work is based on her thesis, which was conducted at The Catholic University of America.

Kevin J. Crowley, PhD, is a staff psychologist at Capital Institute for Cognitive Therapy in Washington, DC. He is also an adjunct instructor for the Psychology Department at The Catholic University of America.

Diane B. Arnkoff, PhD, is a professor Emerita of Psychology at The Catholic University of America, where she served as director of Clinical Training and co-director of the Anxiety, Mindfulness, and Psychotherapy Integration Research lab.

Carol R. Glass, PhD, is a fellow of the American Psychological Association and the Society for the Exploration of Psychotherapy Integration. She is a professor of Psychology at The Catholic University of America in Washington, DC.

David A. Jobes, PhD, is a professor of Psychology and an associate director of Clinical Training at The Catholic University of America, where he is also the director of the Suicide Prevention Laboratory.

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