Shneidman’s greatest questions: Where do you hurt and How can I help?

Shneidman’s greatest questions: Where do you hurt and How can I help?

After I had a meltdown in late 2005 and was slowly recovering in 2006, I was taking a psychometrics class at college to earn my psychology degree. Psychometrics is a fancy name for psychological testing and validating tests and assessments on various things. As I was recovering from a deep suicidal depression, I was curious to see if there were any measures on psychological pain in suicide. I wrote my first draft of the term paper with 20 some odd articles all doing various risk assessments and testing of suicide ideation but none of them dealt with psychological pain, which was what I was aiming for.

The professor tore my first draft apart and even, however vaguely, accused me of plagiarism. I wanted to get a good grade in this class because it would help my further advancement in psychology. I went back to the drawing board. I searched for pain and psychological pain in the library databank. About only 5 articles showed up, at the time. I am sure I was doing it wrong. I looked up the articles and found Shneidman and Holden. Dr. Holden was based out of Queen’s University in Canada. He came up with a psychache assessment that I found useful in my therapy. I kept that article and shared it with my therapist. Then I queried everything on Shneidman and hit the jackpot. His work was in psychache, psychological pain. I read everything I could on him and his followers. I saw my idol David Jobes’s early work on the Suicide Status Form. It wasn’t appealing to me at that time. I was more interested in the psychache of the matter.

I read Dr. Shneidman’s book, The Suicidal Mind. Holy crap! This was about “me”. I knew I had to read everything this guy wrote but it measured in the hundreds so I focused on what was available now. I tried to read his books that were solely written by him but they were few and outdated. He wrote many chapters. The two questions that I kept coming across were “where do you hurt” and “How can I help?” No one had ever asked me those questions all my years in therapy. Not even my current therapist at the time asked until I brought it up to her.

These questions were the basis of how he helped suicidal people over his career. He brought them other options for suicide by learning things about their predicament. Then he ranked them in order of importance. As he slowly worked with them, suicide became less of an option on the list, which was good. It didn’t mean their risk of attempting was any lower but they could see that it wasn’t something that had to do right then and there as there were other options. That is what suicide prevention is, finding other solutions to the problems someone is facing other than suicide. Sometimes it works, sometimes it doesn’t. There was a case in which Shneidman talked to a Hispanic male who attempted suicide by gun shot. He blew off half his face and needed multiple surgeries and was in intense pain from his injuries. Dr. Shneidman counseled this man until he was well enough to leave the hospital. They kept in touch but as time went on, the contact got fewer and fewer. The young man died by suicide by that method a few years later. It was a sad case. The importance of the story is that contact is useful even after the initial attempt has passed, be it with postcard or phone calls or text messages. This isn’t an entire protective factor but it can be. Some people who think of suicide and even go to plan it, get through their circumstances never to think about it again. Others make an attempt and it is a kind of “wake up” call and they never think about doing something like that again. Then you have the people that are chronically suicidal, who make multiple attempts. These are the people most at risk of ending their lives by their own hand. It is these people that need the most help and patience. This is where the framework CAMS (Collaborating, Assessment, and Managing Suicidality) comes in handy. Check out their website

talking therapies and other things

A fellow blogger asked about talking therapies and it got me thinking that I never really wrote about this before. I have been through most psychotherapies, but mostly to do with psychodynamic. I never was one for DBT (dialectical behavioral therapy) or CBT (Cognitive behavioral therapy). I wanted to get better quick and these therapies, you had to do homework and stuff. It just made me more depressed. I know some people have sworn by them and have been helped by them. I know they work because I have seen the studies on them. Most recently, CBT is making waves with veterans who have suicidal thoughts. They use what is called Brief CBT and it helps the soldiers faster than “treatment as usual”. Treatment as usual is just a term used to describe what is standard care for someone. There are some specifics about it but I can’t remember them off the top of my head at the moment.

For suicidal patients, I still believe the standard of care should be CAMS, Collaborating, Assessment, and Managing of Suicide. It is a framework that has been shown to work best with suicidal people and its assessment, the SSF (Suicide Status Form) is very useful in getting to the bottom of a suicide crisis. People don’t know more about CAMS because they rather rely on their own method of treating someone who is suicidal, which is the “standard of care” but it doesn’t work. If you are suicidal, you agree you aren’t going to kill yourself and if you can’t agree with that, you are placed in the hospital. CAMS allows for outpatient treatment to occur and only takes about fifteen minutes in a 50 minute session to work on. I have written about CAMS. You can search for it in my archives.

I didn’t sleep well last night. I was just tossing and turning most of the time. I couldn’t get comfortable. I was hot, cold, cold, hot. I just didn’t get it. I finally took my meds around 0230 this morning and then was up till around 0530. I didn’t have supper and I wasn’t hungry. My appetite has been minimal these days. Going to my father’s place was a chore and left me more tired than I was before I left my house. I was only there for about ten minutes. He is a pain in the ass as he hasn’t been taking his water pill and then wonders why he is swollen. Pisses me off.

Now I am home and feel like I should nap. Except I don’t want to nap. I am wicked cold and need something to warm me up. I would have coffee but I don’t want the jitters. I still am not over my little caffeine overdose from the other day. Never again will I drink back to back cups of coffee. It was too much for my system. I felt great but not in the long run. It wasn’t intentional. I just wanted to stay up as I had again didn’t sleep too well. Think I might have tea next time.

CAMS/SSF Collaborating, Assessment, Managing Suicidality/Suicide Status Form Blog

The CAMS/SSF Blog by G. Collerone all rights reserved, copyright 2015

Despite the increase in awareness of suicide as a major psychological health problem, gaps remain in training programs for mental health professional, or even health care professionals who often come into contact with suicidal patients in need of these specialized assessment techniques and treatment approaches.

CAMS (Collaborating, Assessment, and Managing of Suicidality) was developed to modify clinician behaviors in how they initially identify, engage, assess, conceptualize, treatment plan, and manage suicidal outpatients. At the heart of the CAMS approach is an emphasis on a strong therapeutic alliance where counselor and client work closely together to develop a shared understanding of a client’s suicidal phenomenology.

CAMS is designed to specifically target suicidal ideation and behavior as the central clinical problem, independent of diagnosis. Within CAMS, there is a basic belief that suicidal thoughts and behavior represent a fundamental effort to cope or problem solve, in pursuit of meeting legitimate needs (e.g., needs for control, communication of pain, or an end to suffering).

Ironically, the counselor’s capacity to understand and appreciate the viability and attraction of suicide as a means of coping provides the essential ingredient for forming a strong therapeutic alliance where more adaptive methods of coping can be evaluated, explored, and tested.

Philosophically speaking, CAMS emphasizes an intentional move away from the directive “counselor as expert” approach that can lead to adversarial power struggles about hospitalization and the routine and unfortunate use of coercive “safety contracts” (Jobes 2000, 2006)

Suicide Status Form, the CAMS assessment tool, uses Likert and qualitative open ended items related to the client’s psychological pain, stress, agitation, hopelessness, self-hate, and overall suicide risk. Throughout the assessment process, the client’s perspective is treated as the assessment gold standard. We suggest the regular use of brief symptom assessments collected at every clinical contact is analogous to medical personal routinely taking a patient’s vital signs to monitor overall physiological functioning and health.

This blog will discuss in detail the underpinnings of the CAMS model as well as its assessment tool, the Suicide Status Form (SSF). This blog uses multiple references that will be posted at the end of the post.

The reason I am writing this Blog is not only to disseminate the information of David Jobes’s work, but also to bring something that is easy to administer in a timely fashion, provided the client is English speaking, literate, and cooperative. The beauty of this assessment tool is that it can be used as part of the client’s medical record. There doesn’t have to be additional paperwork with the SSF as it already has the documentation required. Granted, I am not a clinician, so guidelines may be different but I think most places and practices has to have the axis’s and GAF score. I could be wrong about this but do what is best for your practice and clinic.

Another reason I am writing about this important work is that it saved my life and countless others. I believe in this so much that it is all I talk about when someone mentions suicide prevention. That is how strongly I believe in this brilliant seminal work. I think that if every clinician had this at their disposal, less suicides would happen. And isn’t that the goal that should be achieved?

CAMS, the Collaborating, Assessment, and Managing of Suicidality, came about from the need of one clinician-researcher to keep track of suicidal patients, to monitor their progress, to assess, manage, and collaborate with suicidal clients. The framework and research was done over a period of twenty-five years. The need to have something better than “no suicide contracts” and long assessment forms had to happen. There had to be an evidence based treatment and assessment tool out there as the days of long hospitalizations for depression were over. Many clients who were deeply suicidal were only kept for one to three days, tops. Soon as they were admitted, talk of discharge were discussed, much to the chagrin of the outpatient clinician. What was going to help the clients see another way out of their pain and misery?

In his book, Managing Suicidal Risk, Jobes realized four assumptions of why clinicians were reluctant to use suicide assessment instruments:
• Over reliance on clinical interviewing
• Wide spread perceptions that suicide risk assessments are clinically intrusive or simply too long
• Most existing instruments are atheoretical. Clinicians do not know the meaning of an obtained risk score
• Common perception that these instruments fail to fundamentally capture essential but elusive aspects of suicidality.
The end result was coming up with a framework and assessment tool that was evidence based, easy to administer and code, assess overall suicide risk, and have a treatment plan in place that both clinician and client agreed on. Behind the name of “managing suicide risk”, there is a double meaning of clinical work with suicidal clients is best performed by collaborating, managing the issue with the client, and in turn such an approach makes the whole challenge of working with suicidal risk much more manageable for the clinician. CAMS can be quickly learned and readily used with new cases, or with ongoing cases, wherever suicide risk is present. It is not meant to be a stand alone treatment but rather serves as a practical method that can be added to a standard treatment approach, a tool already existing in any mental health professional’s toolbelt.

The SSF (Suicide Status Form) is the tool that is used with CAMS and is made up of seven different pages that are divided into three phases of clinical care

• Index Assessment/treatment planning (pg 1-3)
• Clinical tracking (pg 4-5)
• Clinical outcome (Pg 6-7)

Thus, there are three distinct phases of the SSF that I will attempt to discuss in detail that are used within the process of using CAMS with any suicidal client. (I.e., there are distinct phases that include a beginning, a middle and an end.)

The first phase of CAMS require the first three pages that assess the suicide client. It uses four distinct sections. The first section (A) are Likert ratings. The first three Likert assessment construct (pain, perturbation, press) are based on the work of Edwin Shneidman (1988) and these make up the “cubic model of suicide”. The 4th item is hopefulness bases on Beck’s work. The 5th item, self hate, is based on Baumeister work of escape theory of suicide. He links intolerable perceptions of self to a need for suicide escape (see this blog post for more information on his work).

Psychological pain or as Shneidman has named it, psychache, is a profound and seemingly unbearable suffering that exists in the mind’s eye of the suicidal person. The psychological threshold has been exceeded and suicide occurs. Not everyone’s tolerance of psychache is the same. It is unique to each suicidal client.

Press (stress) is what Shneidman borrows from Murray (1938). For our purposes, the term refers to largely external (sometimes internal) pressures, stressors, or demands that impinge upon, touch, or psychologically affect an individual. External things such as relational conflicts, job loss, or events that occur in life that create significant distress. Alternatively, however, internal stressors such as command hallucinations can be similarly distressful. Presses are intimately linked to overwhelming feelings: the perception that I am overpowered by psychological demands. For the sake of clarity, further descriptions of press will be referred to as stress.

Perturbation, the second ‘P’, is a unique and crucial construct that is distinct and different from psychological pain. Shneidman defines perturbation as the state of being emotionally upset, disturbed, and disquieted. In his thinking, perturbation includes both cognitive constriction (narrow-minded or one way thinking) and need for self-harm or ill-advised action. It can be described as the “need to do something” to change the unbearable situation.

The “cubic model of suicide” conceptualizes suicidal behaviors that occurs from the synergy of these three constructs (psychache, perturbation, and press (stress); also known as the three P’s) They are rated on a Likert scale of 1-5. It is believed that should a score of 5-5-5 occurs, suicide is imminent and is therefore lethal.

This Cubic Model of Suicide is the hub of the SSF. It provides a three dimensional window into the client’s suicidal mind that meaningfully eclipses any one dimensional linear way of thinking about suicide risk assessment.

The next item on the SSF in Section A is hopelessness. No single construct has been more highly correlated with completed suicide than hopelessness. Jobes felt it imperative to include hopelessness as a key SSF construct. It provides an organizing focus for treatment. The therapist must be “hope vendors”. This notion strikes him as being uniformly true and central to successful treatment in general and particularly when working with suicidal people.

The next item in Section A is self-regard (self-hate). Baumeister conceptualized suicide as an escape from self. In his view, suicidal people are fundamentally driven to psychologically escape as a way to get rid of themselves. According to Baumeister’s theory, one’s negative view of self can become so unbearable (i.e., one’s self-loathing and self-hate is so extreme) that suicide becomes a compelling means to escape intolerable perception of self. Simply put, there is an intense psychological need for escape. It is perhaps self-evident that people who love themselves are fundamentally comfortable with who they are and most likely are not inclined to take their lives. Thus the beauty of Baumeister’s conceptual approach is that it captures two essential components of suicide struggle, the need for escape and the core importance of the self.

The behavioral assessment of suicide risk is the final component of the SSF. This construct, the Likert question of overall risk of suicide, does not cite any theorist. In this regard, the 6th item simply asks the client if they will or will not kill him or herself. The question is asked to the obvious implications for life and death and determines the medicolegal challenge to whether there is “clear and imminent” risk for suicide behavior. Suicidal states are much more shades of gray rather than crystal clear. They are hardly ever “clear”. And imminent is further convoluted as it could mean this second, later today, or sometime next week. While these definitions are elusive, these terms are important for the safety of the client and have significant implications for the potential liability of the clinician should a complete suicide occurs. Therefore, it made sense to include this risk as a final Likert construct on the SSF.

Next section: Qualitative SSF Assessments

This is a novel idea because most psychological assessment tools are either qualitative or quantitative. The SSF includes both to provide a much fuller picture of virtually any suicidal state. The three different qualitative assessments are 1) the Likert prompts, 2) Reasons For Living vs. Reasons For Dying (RFL/RFD), and 3) the one thing response.

The Likert prompts provides the clinician information about the client’s suicidal mind in his/her own words. For more information about the coding of these responses, see pages 18-19 of the book. But for the most part, in my opinion, these responses are straight forward to what the client is dealing with in this crisis and what is driving them to think suicide is the answer.

The SSF RSF/RFD was built upon the important work of Marsha Linehan (1983). She developed the reasons for living inventory. Linehan had the novel idea of studying suicide risk assessment in an entirely different way. With dozens of studies dedicated to risks factors and why people might want to die, Linehan argued that an equally compelling assessment notion was the value of examining why any person might want to live. The absence of RFL could be inversely correlated to increased suicide risk. In an opposite fashion, Jobes built the reasons for dying inventory in the same assessment (Jobes and Mann, 2000). These assessments provide a tool that parallels no other risk assessment in the literature that tells a picture of the client’s suicidal mind, in my opinion.

The one thing response gathers information directly from clients about the one thing that would make them no longer suicidal. This provides the clinician with potentially more clinical information that leads directly to a treatment intervention. For example, if the client state that being in less pain would make them no longer suicidal, the clinician can work with the client to decrease that pain.

Section B has the SSF empirically-based risk variables on the second page of the initial form. These risk factors have been well researched risked factors that are the best variables for suicide risk.

Section C is the wonderful piece of the SSF. It is the section where both the client and clinician come up with a treatment plan, together! In this section, treatment goals, length of treatment, crisis response plans, and specific interventions are discussed. For the Crisis response plan example, please check out this blog post. It emphasizes what the client will do should he/she become intensely distressed, impulsive, and suicidal. These measures are clearly planned in anticipation of potential crises. This becomes a contract where the client then signs in agreement.

The tracking form (pg 4-5) omits sections b and c. It assesses similar to the initial form. It was created so that the suicidal feelings are “tracked” and monitored. This is to be used until the suicidal thinking has resolved for three sessions. The outcome form (pg 6-7) describes the overall experience of the crisis and provides feedback to the clinician. It also assesses the Likert ratings to be sure the suicidality has been sufficiently dealt with. If the client should become suicidal at anytime before the outcome is used, then a new initial form should be evaluated again.

All three forms then have sections that provide post session evaluations. There is a space for clinical notes as well as the mental status of the client. It also has information regarding the outcome of the appointment and when the next scheduled appointment is. That is the beauty of this assessment tool. No extra paperwork!

here is the DSM IVR Form

Update 23/November/2016 Dr. Jobes has a 2nd Edition of the Managing Suicide Risk that is available through eBooks. It has the DSM V form of the SSF. I am unable to load it at this time, as I do not have his permission to load it on my blog. If I am able to find an electronic version of it, I will place it here instead of the DSM IV version. Thank you for reading.

Jobes, D. A., Moore, M. M., & O’Connor, S. S. (2007). Working with Suicidal Clients Using the Collaborative Assessment and Management of Suicidality (CAMS). Journal of Mental Health Counseling, 29(4/October), 283-300.

Jobes, D. A. (2006). Managing suicidal risk: A collaborative approach. New York, NY: Guilford Press.

Jobes, D. A. (2012). The Collaborative Assessment and Management of Suicidality (CAMS): An Evolving Evidence-Based Clinical Approach to Suicide Risk. Suicide and Life Threatening Behavior, 42(6), 640-653.

Murray, H. A. (1938). Explorations in Personality. New York: Oxford University Press.

Linehan, M., Goodstein, J., Lars Nielson, S., & Chiles, J. (1983). Reasons for Staying Alive When You Are Thinking of Killing Yourself: The Reasons for Living Inventory. Journal of Consulting and Clinical Psychology, 51(2), 276-286.

Jobes, D. A., & Mann, R. E. (1999). Reasons for Living versus Reasons for Dying: Examining the internal debate of suicide. Suicide and Life-Threatening Behavior, 29(2), 97-104.

Jobes, D. A. (2009). The CAMS Approach to Suicide Risk: Philosophy and Clinical Procedures. Suicidologi, 14(1).

Baumeister, R. (1990). Suicide as Escape From Self. Psychological Review, 97(1), 90-113.

Shneidman, E. S. (1993). Suicide as psychache: A clinical approach to self-destructive behavior. Lanham, MD: Jason Aronson.

Shneidman, E. S. (1996). Suicide as psychache. In J. T. Maltsberger & M. J. Goldblatt (Eds.), Essential papers on suicide (pp. 633-638). New York, NY: New York University Press.

Oordt, M. S., Jobes, D. A., Fonseca, V. P., & Schmidt, S. M. (2009). Training Mental Health Professionals to Assess and Manage Suicidal Behavior: Can Provider Condience and Practice Behaviors be Altered? Suicide and Life-Threatening Behavior, 39(1), 21-32.

copyright 2015, Collerone, G

selected reading for CAMS

Copyright 2014, Midnight Demon p 10-11. All rights reserved. Collerone, G

David Jobes is my idol. I really love his works and he is a great suicidologist. He really gets what it means to be suicidal and better than that, he wants to help suicidal people. Most clinicians do not want to deal with suicidality with a ten foot pole. They are afraid of the risks involved, from liability to malpractice to ethical concerns. Dr. Jobes has written about all of this and with a passion created a clinical framework to deal with this population. The framework is called CAMS (Collaborating Assessment, and Managing of Suicide). It is a philosophical yet empirical theory that has helped thousands of suicidal people get out of their suicidal thinking and on with their lives. CAMS was developed specifically to modify clinician behaviors in how they initially identify, engage, assess, conceptualize, treatment plan, and manage suicidal outpatients. It is a brilliant concept that is much needed in outpatient therapy as inpatient treatments have gone by the way side and insurance companies have dictated more on treatment than clinical matters. The heart of CAMS is the emphasis on a strong therapeutic alliance where counselor and client work closely together to develop a shared understanding of what brings the client to think about suicide. CAMS is similar to the Aeschi model, where the clinician is open to hearing the clients story of why they are suicidal. It is a patient oriented model rather than a physician oriented model.

These CAMS model has an assessment tool called the Suicide Status Form (SSF) and it is used to assess, treatment plan, and track suicidal patients. The cool thing about this assessment is that it multi-faceted and is not restricted to one mode of therapy or type of clinician. It can be used across all disciplines and types of therapists (DBT, CBT, psychodynamic, etc.) As long as there is a willingness to adhere to the principles of putting the client first, that is the first step in the right direction.

The SSF is a seven page assessment tool that is used to initiate, track and follow the outcome of suicidality. It was created so people who are suicidal are not lost to follow up. More can be said about this in Jobes’s book, Managing Suicide Risk.

I have used the SSF in my therapy. But I have to confess that my therapist and I never followed through completely with it. We would use the initial and the tracking forms but never quite got to the outcome phase of the assessment. Because I felt like it was my idea, and she wasn’t into changing her style of treatment, it was difficult to follow through. But that is okay because I am still here regardless. We mostly use the SSF to assess my psychological pain, reasons for living/dying, and the level of my suicidality.

I will repeatedly talk about the works of Jobes, Shneidman, and the Aeschi model throughout this book. It is because I think there is not enough awareness of this in the world of psychiatry, psychotherapy and psychology. And there is even less in the training of therapists and future psychiatrists. It really is a shame that not enough awareness of suicide is mentioned in the course of graduate college training and it is often left up to the students to figure it all out on their own, if at all. Usually it isn’t until a suicide or attempted suicide happens that people have hindsight and that isn’t always 20/20.