Episode 70 Transcription: Rethinking Suicidality Treatment

Transcript

Episode 70: Rethinking Suicidality Treatment

 

Dr. Robert Boland: 0:02

Welcome to the Mind Dive podcast brought to you by the Menninger Clinic, a national leader in mental health care. We're your hosts, Dr. Bob Boland and Dr Kerry Horrell.

Dr. Kerry Horrell: 0:11

Monthly we explore intriguing topics from across the mental health field and dive into hidden realities of patient treatment.

Dr. Robert Boland: 0:18

We also discuss the latest research and perspectives from the minds of distinguished colleagues near and far.

Dr. Kerry Horrell: 0:23

So thanks for joining us.

Dr. Robert Boland: 0:26

Let's dive in. So, welcome to the podcast. We've been trying to get these two on for a bit, so we're very excited that they're here to talk with us about suicide, you know. And I don't think we need to spend too much time. You'll tell us a bit, but still, like, a crisis that's still increasing despite efforts.

Dr. Kerry Horrell: 0:51

And this month, the month of September, is National Suicide Awareness Month.

Dr. Robert Boland: 0:54

Yes, thank you.

Dr. Kerry Horrell: 0:56

So we're excited to have you both on.

Dr. Robert Boland: 0:58

You're here really just not to tell us about the problem, but to bring some hope before we go. First of all, we have on Adrian Lira, PhD. He's a bilingual, licensed professional counselor, supervisor, and nationally certified counselor with expertise in clinical practice, higher education behavioral health. He serves as Director of Professional Development at the Menninger Clinic and is a clinical assistant professor at Baylor College of Medicine, and there he oversees hospital-wide training, continuing education, and workforce development initiatives. He holds a PhD in counselor education and supervision from Sam Houston State University, an MA in clinical psychology from the University of Houston Clear Lake, and a BS in psychology from the University of Texas at El Paso. His areas of specialization include multicultural competence, trauma-informed care, clinical supervision, supervised suicide assessment and treatment. He serves on national committees such as the National Board of Certified Counselors, the Board of Directors and the APA's Interdisciplinary Minority Fellowship Program Review Panel. His professional efforts center on advancing equity in mental health care, enhancing post-licensing development in the behavioral health workforce. All right.

Dr. Kerry Horrell: 2:11

Welcome, Dr Lira.

Dr. Robert Boland: 2:12

Welcome, Dr Lira.

Dr. Kerry Horrell: 2:13

We also have with us Dr. Patricia Daza, who I'm going to also refer to as Patty. Patty is a senior psychologist and the Director of Psychological Services at the Menninger Clinic. She previously served as Program Director for Compass, our program for young adults. In addition to her clinical roles, Dr. Daza is the Director of Clinical Training for Menninger and an associate professor in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine.

Dr. Kerry Horrell: 2:41

Board- certified and clinical psychologist, Dr. Daza earned her doctorate in clinical psychology from the University of Houston, Go Coogs, from which she also graduated magna cum laude with a bachelor's degree in psychology. She completed an internship at the University of Texas Medical Branch in Galveston and a postdoctoral fellowship at the University of Texas MD Anderson Cancer Center. Dr Daza speaks frequently on depression, smoking cessation, motivational interviewing, and suicide prevention. She serves as a site visitor for the American Psychological Association's Commission on Accreditation. And I do like to say Patty is my, she's my Menninger mom, because Patty's been my boss at every stage of my training here, because I was an intern and a fellow. She was psychology director, training director. She also was over Compass, which is where I've pretty much exclusively worked on campus, and now she's Director of Psychology.

Dr. Patricia Daza: 3:34

So happy to be here with y’all.

Dr. Kerry Horrell: 3:35

So happy to have you both here, and you both also serve as our trainers for our hospital's program for suicide assessment and management, which is really what we want to talk about today. Again, especially in light of this being the month of suicide prevention. So, thank you both for being here.

Dr. Robert Boland: 3:51

Yeah, so why don't we start the usual way? Just tell us, like, how you got interested in this and working with folks you know, who struggle with suicidal thoughts.

Dr. Patricia Daza: 4:00

Yeah, I can go ahead and start if that works. I was lucky enough to work here years ago when Dr. Tom Ellis, who was our previous Director of Psychology, was here and brought a wealth of both clinical and research experience in suicide and really introduced us to several key people in the field, among those Dr. Thomas Joyner and Dr. David Jobes. And so, when Dr. Jobes came here, he really started that conversation around CAMS. For those that don't know CAMS, the Collaborative Assessment and Management of Suicidality, and we were one of the first places to really look at the data of the effectiveness of CAMS in an inpatient setting. As we'll talk about, most of the work has been done outpatient, so I was lucky enough to kind of get started with that and being here. As you all know, we work with a lot of clients who struggle with suicidal thoughts.

Dr. Kerry Horrell: 4:49

Patty, how long have you been at Menninger?

Dr. Patricia Daza: 4:51

I've been here 20 years now.

Dr. Kerry Horrell: 4:53

I was like your 20-year anniversary.

Dr. Patricia Daza: 4:55

Yeah, very exciting.

Dr. Kerry Horrell: 4:56

You've worked inpatient for a long time and I'm seeing especially the integration of CAMS in our programs.

Dr. Patricia Daza: 5:02

Exactly, and what I love about it, and we'll talk about it with Dr Lira, is we're really starting to see more of this shared model that all clinicians coming into the clinic are getting trained in CAMS-informed treatment.

Dr. Robert Boland: 5:14

All right. So, Adrian, how about yourself?

Dr. Adrian Lira: 5:17

Yeah, I think working here at Menninger definitely introduced me to the CAMS model, which is great. But I think for me, one of the things that was really a driving force for working and understanding suicide and what was really working from an outpatient perspective. I did a lot of work prior to Menninger in outpatient, and I really saw just the impact. A lot of it was even my own anxiety with working with suicide, not having inpatient opportunity like I do at Menninger. So that was really really nerve-wracking and scary. So, one way to face that is by learning more, becoming educated on CAMS, and really using that. So, I think that's one of the reasons that I really gained an interest in understanding and working with folks with suicide. And also from an educator perspective, right, wanting to create more competencies and comfort with clinicians and working with suicide. Because, as we all know, we just never know when it's going to present itself. It's a matter of time before we are all working with a client or a patient that is suicidal.

Dr. Kerry Horrell: 6:14

And Adrian, I have to say, having been in some of your trainings before, you are such an excellent teacher. You're so down to earth and I think you're just so well placed to be doing this work.

Dr. Adrian Lira: 6:24

Thank you, appreciate you.

Dr. Kerry Horrell: 6:24

So let's hop into talking a little bit about CAMS. Patty, as you said, that's the Collaborative Assessment and Management of Suicide. Can you please just give us a little bit of an overview of that model? Like, what venue is it typically done in? Like, what's sort of the goal of CAMS in general?

Dr. Patricia Daza: 6:46

Definitely, the work was mainly, as I said, talked about and done in outpatient. A lot of research and clinical work, but it's generally focused as a 12-session outpatient model, three months essentially, where we're working collaboratively. And that's kind of the goal of working with the client. To look at ways as to what might be drivers of their suicide and have a very frank, open conversation about it. What I love about Dr. Jobes is he didn't try to reinvent the wheel. What was the most evidence-based, already out there and implemented things like Schneidman's model, Beck's model, et cetera, and then getting not just an assessment of what's happening, but a therapeutic framework to really work on addressing these drivers of suicide.

Dr. Kerry Horrell: 7:23

Dr. Lira anything to add?

Dr. Adrian Lira: 7:25

Absolutely. I think the other part that I think is important when working with CAMS is understanding the four pillars of CAMS. So, coming at it from empathy, I think, is key. I think that's important. I think that really makes it different. We're really empathizing with the client's suicidal wish, which might sound interesting and scary, but we're really not judging. We're saying, okay, we're trying to understand and get your perspective.

Dr. Adrian Lira: 7:48

The second pillar is collaboration. Right, so we're not leading; we are working alongside the client. In fact, with CAMS we are sitting next to the client, in part to decrease that power differential but also to kind of see the client's perspective and we're sitting next to them. I think that's more collaborative. And then the third pillar is honesty. We're going to have an honest conversation with clients and family around suicide. I think that also makes it different. We kind of broach the topics that Dr. Daza mentioned with the CAMS assessment and then of course it's focused on suicide. So, I think that those four pillars really make it different. I think it makes clinicians more comfortable, and it makes clients seem less defensive. It creates safety and it improves rapport.

Dr. Kerry Horrell: 8:33

Yeah, what I think about what you just said too, about what you said earlier, Adrian, about how working outpatient with suicide can really freak a lot of people out. And I think this is one of the complexities of folks who are suicidal is that these are some of the times that people who need the most care or they really need to be seen by clinicians. And this can be hard for people to get into care because people are like, oh, if they're suicidal, I don't feel comfortable seeing them outpatient. And so, again, I think one of the things that I love about CAMS is that it gives people like structure and support and like ways to work with folks at an outpatient individual level where it does feel like then there's something more supportive than just well, this is a scary thing to bring into my practice.

Dr. Kerry Horrell: 9:13

And the other thing I was thinking about that I wanted to say that I appreciate about CAMS too is that CAMS is an intervention for suicide. It's not an intervention for depression; it's not an intervention for another disorder. It's an intervention for suicide. We recently had on Dr. Christine Yu Mutier, and she's the current president of the American Foundation for Suicide Prevention. And she talked to us about that, like that: to prevent suicide, we have to treat it. We cannot just treat depression and hope that suicide goes away, that it's just like, oh, if we treat you know a disorder, then suicide, like suicide, needs an actual treatment.

Dr. Patricia Daza: 9:50

That's so central. Thank you for bringing that up here, because that is the CAMS especially doesn't look at suicide as a symptom of depression or vice versa. The goal is to treat and what is the main thing that we're going to target, especially both an outpatient and inpatient. We get very challenging clients who come with a lot of different things and over time we can get focused on one thing like depression or anxiety, where we're losing sight of the main issue, that is really suicide. So we want to keep that at the forefront in our session, at least inpatient. We see them twice a week. Once a week we're always going to be addressing the suicide and there's ways to do that, obviously in outpatient. So definitely the main target that we're addressing.

Dr. Adrian Lira: 10:30

So yeah, the other thing I was going to mention is really focusing on the suicide drivers, right. So, a lot of assessments, you're looking at the risk but not so much the treatment, like you mentioned, Kerry. But with CAMS, you really are identifying what is causing this person to become suicidal and how do we address that. And then there's a suicide-specific treatment plan that I think also makes clinicians feel more comfortable. And again, there's that collaborative work with patients and clients.

Dr. Robert Boland: 10:54

It's interesting that it differentiates between an individual's wish to live from their wish to die. And that certainly is something I've heard theoretically before and stuff and it's always kind of interesting that you know that they're neither mutually exclusive or

Dr. Kerry Horrell: 11:09

It's not one spectrum.

Dr. Kerry Horrell: 11:10

I feel like usually you would think it's on one spectrum. If you want to live, then you don't want to die. If you want to die, then you don't want to live, and CAMS says no.

Dr. Robert Boland: 11:18

That's what I was trying to say. Thank you.

Dr. Kerry Horrell: 11:19

Yeah right

Dr. Robert Boland: 11:21

No, no, it's good, but I mean, can you just say more about that and why, and why you see these things as distinct?

Dr. Adrian Lira: 11:28

Yeah, I think it's important to look at both the wish to live and wish to die in separate things, because it really helps us to understand the patients or the client's suicidal ambivalence, right and see that there is an ambivalence there. A lot of people going through a suicidal crisis they don't realize that it's possible to feel both at the same time. They want to die in the moment, but also in some part they also want to live. And in CAMS we really talk with clients about this to help them see that these conflicting feelings can coexist and often do coexist, and that moment of insight can be powerful.

Dr. Adrian Lira: 12:04

I think it can help someone realize that there is still a part of them that wants to live and that realization can make a big difference in how engaged they are in treatment. And it's not about the therapist or us convincing them to live. We're not telling them they should live, we're just bringing it to their awareness that they want to live. And it's about the client discovering that they still want to live and it's even just a small part of them in the moment. They still have that desire. So I think that's why it's important to separate the distinction between wish to live versus wish to die.

Dr. Patricia Daza: 12:34

Yeah, and that's the complexity, I think, of suicidality, that the things that are on wish to live, family and protective factors might also be on wish to die, like being a burden to our family. And so that's the piece that we're trying to really tease out in that therapeutic session to help them really understand that and flesh out that ambivalence.

Dr. Kerry Horrell: 12:54

My sense that when I've done CAMS with patients is like these are light bulb moments when you know we're saying, what makes you want to die. That seems to come fairly easy for a patient who's inpatient for suicidality. They're, like I feel like a burden, I feel like I can't overcome my problems. And then we say, well, if we hold that as something separate than wanting to stay alive, and they're like, well, yeah, I do like guess ideally, I would be able to stay alive, and help them name, like what are the things that make you want to stay alive? And to name I think you said it perfectly, Adrian like the ambivalence. There's tension here and I think that tension gives us as clinicians that space to get our foot in the door of like we're not going to close down, we're not going to try to convince you that those things that make you want to die are gone.

Dr. Kerry Horrell: 13:37

We were going to use those, but we also don't want to act like there's not another side of the story too. And I feel like I've seen patients when you say both those things together like whoa, yeah, this is complicated.

Dr. Patricia Daza: 13:47

And that part is so important. We're not trying to convince, right, because you could use those same things and say, you need to live for this or they need you, and then we're getting out of really validating their experience. So, we want to be in that with them. That struggle.

Dr. Adrian Lira: 14:03

Yeah, and I think also during that suicidal crisis, right, they are only thinking of the dying piece. They're not necessarily in that moment thinking of the living, but when they think back, they're like, oh okay, yeah, there was a part of me that did want to live. And with that realization, I think, there comes hope. A lot of times that hopelessness is there, right, which is part of the suicidal wish. But instilling some hope in that wish to live, I think, makes a difference.

Dr. Kerry Horrell: 14:29

So, obviously in the name of CAMS is the word and I want you guys to say more about this. But because here's something I think about a lot. We know that feeling trapped and feeling like you don't have control can increase somebody's feelings of suicidality. We also know that when people are saying they can't keep themselves safe, this is one of the only times where people's rights can be taken away, like they can be involuntarily be sent to treatment, like there are ways in which people who are suicidal there can be again this sort of catch 22, this, this painful conflict of I feel trapped, I don't want to be in treatment, but it's like sometimes, again, they get that choice taken away from them. I am so curious what you guys think about why, then, a collaborative approach is so crucial to working with people who are suicidal?

Dr. Patricia Daza: 15:12

Yeah, I think a lot of the reasons that you said where there's so much risk in them being open and vulnerable because it does, it can come with what they see right? Consequences either being put on unit restriction or being hospitalized, I think, if it's an outpatient.

Dr. Patricia Daza: 15:34

But that's the work about the trust that hopefully builds over time. And saying the honesty pillar that Dr Lira was talking about right, that we have to say the reality of these are the rules, quote things that we have to do but we're going to work really hard to keep you out of the hospital or to have to put you on a safety restriction and being honest about our own tunes. Like we say, share our mind with the client as much as possible. But it's only in that collaboration that hopefully that trust develops. Even Dr. Job says it's almost like provocative and he'll say it is provocative to say we can't completely take away that choice and that's hard to hear in terms of the suicidality. But does it have to be the very first option that people are thinking in times of distress? Could it be like number eight or nine that we're working on other skills to be able to manage that? And that's super important for somebody suicidal to hear because there's a strong attachment to that right. It's an escape, it's like my out, and so we have to very openly talk about that.

Dr. Adrian Lira: 16:30

Yeah, I was going to say that I think the other part with the collaborative work is, in a way, it puts the client in the driver's seat, and they are increasing buy-in by having it be collaborative, where we're not doing CAMS on the client or we are assessing them only right? We're hearing their story, we're helping the client, felt heard and felt like we're getting them, and I think that's the importance of the collaborative approach.

Dr. Kerry Horrell: 16:54

You know, I remember when I was lucky enough, I did my camp training with Dr. Ellis, who again is an expert on suicidology, and I remember one of the things he talked about was human reactivity. It's just like a normal part of being human, like it's a, it's a normal reaction when someone says, "We can't do this to kind of have something your brain be like, "Well, why not, should I do it? Do I need to do it? Don't push the red button, but what if? Well, what happens if I push the red button?" Like we react this way, and so I think a lot of suicide treatment maybe not a lot, but like some suicide treatment that I've heard of is very focused on like, well, then, don't kill yourself. And I think for so many people that's like this is my one thing that I'm holding in mind is maybe going to help me feel better.

Dr. Robert Boland: 17:32

Oh yeah, some people talk about it as a type of control.

Dr. Kerry Horrell: 17:34

Yeah, and so then to say, well, no, we're not saying like, take that off the table, but can we stop and see if there's other things on the table. I think that's a really it lowers that reactivity, it lowered that sense of feeling trapped.

Dr. Kerry Horrell: 17:45

I think to be like we're going to do it, we're actually going to look at these papers together, we're going to look through this together and we're going to keep literally

Dr. Patricia Daza: 17:52

A big example of that control is these ideas of safety or no suicide contracts, which do not work, and we speak very openly here about not using those and saying what we can't or should not do.

Dr. Robert Boland: 18:05

You want to say a little more about that for people that don't know it. What would a suicide contract be?

Dr. Adrian Lira: 18:09

So it might say something that's written out with the team and the clients: “I will not engage in self-harm or suicidal behavior. If this happens, I'll be asked to leave the hospital.” You've seen all sorts of things where they're committing to something that's really difficult for them to do and it really again focuses on what they're not able to do. So we talk very openly about safety plans, which says what can I do when I get dysregulated and what do I have input on in terms of what works for me, at least at this time? So it's a different kind of shift into how we think about it.

Dr. Robert Boland: 18:43

Yeah, that makes a lot of sense. I mean, you're kind of getting into some of the you know maybe some of the mistaken beliefs or the myths about suicide, and I know that's a part of the training. Can you just share a bit about some of the myths, and you know that you teach people about and things that people might be sort of like misunderstandings about suicide that people should know?

Dr. Adrian Lira: 19:03

Yeah, I think one of the ones that comes up often is that if you talk about suicide, you're kind of implanting this idea of suicide in their mind.

Dr. Kerry Horrell: 19:11

Yes.

Dr. Adrian Lira: 19:12

I think that's a big one right, when actually the opposite is true. Talking about it, naming it, I think, decreases the risk. The risk might already be there. You're just kind of identifying it earlier on, discussing it and hopefully using some interventions to decrease some of that risk. So I think that's one of the biggest myths out there.

Dr. Robert Boland: 19:31

Yeah, I don't know if we've ever experienced that kind of reaction in patients of almost a kind of relaxation that they can talk about it with you, or relief. I mean, because it's so taboo that even experienced clinicians often just are afraid to bring it up.

Dr. Kerry Horrell: 19:45

Yeah, I've had patients say well, if I talk about this, are like the people in the white coats, going to come get me

Dr. Robert Boland: 19:50

Right yeah.

Dr. Kerry Horrell: 19:52

And this is actually the hardest sell for teens to hear, because teens are already in mental treatment. Obviously they have limited control, but a lot of times I'm always like, if we are talking about this and there's a sense that we are collaborating and talking about this, we actually have more trust in you. You probably have more freedom.

Dr. Robert Boland: 20:09

Plus, we don't wear white coats.

Dr. Kerry Horrell: 20:11

Yeah, actually there's no white coat, but like the sense of, I think, like getting to flip that script, of like the more we actually talk about what's going on, the more a, hopefully the person feels like oh, I can talk about this. But also like, especially people who are afraid of like, oh, what's going to be, what's going to happen about this. Like, the more we're talking about it, the more we know and the more we can actually have some more freedom, I think.

Dr. Patricia Daza: 20:32

Yeah, and especially for families. You know, when it's a younger child or somebody on the adolescent treatment program. Let's say they can have these fears about it and so a lot of its education about just the things you were saying Dr. Horrell, talking very openly about it, and that for many this is already on their minds. We're just hopefully allowing them a safe space to discuss it.

Dr. Robert Boland: 20:52

And any other myths or things you want to bring up.

Dr. Patricia Daza: 20:55

The only other one, I would say. Sometimes people say you know, if somebody's got it in their head, you can't convince them, otherwise they're going to do it. And you know one of the slides that we show which I love to talk about. It's kind of data from, I believe, 2022, but it sounds like 13 or so million people have thoughts of attempting suicide and actually about 3.6 actually attempt. And so, although 3.6 is a large number, I mean that gap in the 13, like that's the space that a lot of people are actually quite ambivalent about it If they don't see another out. And we're trying to provide them ways to say, not that this is going to be an easy process, but together we're going to work on things that are important for you. We even talked about that one thing If we had the magic wand, what would hopefully keep you from attempting to end your life? And those are the things we're going to try to build on in the work we do together.

Dr. Kerry Horrell: 21:50

One of the things we talked about in CAMS, training and I think really in any sort of conversation around suicide, is trying to just name and address the myth that suicide is selfish. And that suicide is something that people get, especially clinicians, might feel resentful or angry at their patients for thinking about that, for acting on those ideations, and again I think this can end up putting people in a box of just like, oh, you're selfish, how could you do that? And I wonder if you can speak a little bit to that myth.

Dr. Adrian Lira: 22:19

Yeah, I think, along with that goes this idea, that sometimes people are seeking attention or attention seeking or, yeah, they're not really serious about it. They're just trying to get people to maybe feel bad for them or something right. But I think that is a myth, because it's not about the attention seeking. It's about the pain and being the person being in pain and how do we help them resolve that pain or work through that pain so that they're not as suicidal anymore, right? So, I think that's one of the of the important pieces to remember when it comes to that, and I think this happens even more so when it comes to teens, I hear that a lot with teens is they're just seeking attention. And for a lot of families, a lot of individuals, it's like you're a teen or you're a certain age, like what kind of problems could you possibly be having? Right? There's also this idea of just not understanding and not wanting to be empathetic about it sometimes or not knowing how to be empathetic maybe is a better way of saying it. That's what I think. But what are your thoughts Patty?

Dr. Patricia Daza: 23:17

Yeah, like Adrian was talking about that, that's really the goal of education that we're trying to do, because, sadly, some of the clients have told us that some of the most deeply felt stigma that they've experienced has actually come from healthcare professionals, and so we want to really provide that education of even things that might seem passive, with what we say, what people say, that obviously they're feeling it very intensely, and so we have to be careful with our word choices and really understand where the pain is coming from and how to address.

Dr. Kerry Horrell: 23:48

Well, I'm thinking about too, even the idea of seeking attention. This is my, I won't get on my soapbox, but maybe I'll just put a toe on it for a second. As an attachment-oriented therapist one of the things I talk to patients a lot about is, of course, you're seeking attention. It's a natural human need, it's one of our dependency needs-- to be attended to. And for people who maybe do feel like one of the only ways that they get help or they get seen is when they're hurting, that's a painful experience in and of itself. So, I guess I'm saying this for clinicians, families or even patients who might hear this and be like, sometimes I have acted out suicidally or in regard to self-harm to be attended to. But that's also painful and it is something that again, like that that could be the case and that there's pain in that too. For folks and I think that's that speaks to level of hopelessness it's like, well, I either die and I've heard patients say this I took a bunch of pills because I was either going to be dead or at least maybe my family would see how badly I was hurting.  Yeah and it's like, yeah, these are painful places to be.

Dr. Robert Boland: 24:46

Yeah, but there's a judgmental part to it.

Dr. Kerry Horrell: 24:48

Yeah.

Dr. Robert Boland: 24:49

You know that kind of notion right again, like this attention is something people shouldn't want to have?

Dr. Kerry Horrell: 24:53

People shouldn't. People need to be attended to. Someone is seeking attention, and I think it Bowlby who said we're only as needy as our unmet needs.

Dr. Robert Boland: 25:02

That's interesting. I'm just going to come back to what you said, though, because it is sort of one of the points of why we're talking about this is that, I mean, there is a lot of therapeutic nihilism about this, and people do sometimes feel that if people want to commit suicide, they will, and there's really no nothing really much we can do. We're just helping the ones who, quote, want to be helped, whatever that means. It is good to hear you talk about this, because there is a sense that it gives people a framework for how they actually can be helpful.

Dr. Kerry Horrell: 25:29

I think this is going to sound nihilistic what I'm about to say, but I actually think it's quite hopeful. So bear with me as I'm going to say this but we're not good at predicting who's going to kill themselves. And even though I think we've done tons of research as a field to look at risk factors and, I think, being able to think about even like the drivers that are named in CAMS, it's important that we name these things. We are not great at predicting it and I find hope in that because in my own work with my patients, I have had several patients who have died by suicide and I've had patients who I was so sure these were the ones who weren't, and they didn't. They got better, and so every single patient I meet, even with their risk factors, even how intense their suicidality is, I can hold out the hope that, like they could get better, because I've seen people get better. And again, I think that, like to me, that's hopeful. Like even people who maybe feel like the odds are totally stacked against suicide, like people get better.

Dr. Adrian Lira: 26:26

With CAMS, it really does give us a starting point to start to understand the person's suicidality. It doesn't give us like a clear picture, it doesn't say "okay, you're no longer suicidal, you are suicidal. I think it just helps, at least the clinician. understand the client more and for sure the client to understand themselves more. And one thing that comes up often in my work with clients and patients is as we start working with CAMS they realize, oh wow, I've been carrying this risk for a lot longer than I even realized. Or maybe I had put it away or I hadn't thought about it, went unconscious for some reason. But I think it does start to highlight some of that risk and they start to understand themselves more. So I think that's a big, big key for CAMS as well.

Dr. Patricia Daza: 27:03

And I do think it's helpful like you said for the therapist to have hope about how do I do this? What if I only have a week? What if I'm in outpatient and doing this alone? And really the data has shown pretty strongly that and right now they have what's called CAMS-BI CAMS, brief Intervention. They're doing stuff in emergency departments, like one session of CAMS, like the assessment and having some kind of discharge plan is showing some pretty significant effects. So just to have and provide that understanding how we think about suicide and hopefully giving them some agency to be able to make some of those changes in their lives.

Dr. Kerry Horrell: 27:41

One thing we actually didn't mention that I do think we should probably say is that CAMS is very evidence-based. There's been significant research that has gone into developing this model and finding that it is effective in alleviating suicidal ideation.

Dr. Patricia Daza: 27:54

Yes, very important, because we want to be doing what the research shows is going to be the most helpful. Very important because we want to be doing what like what the research shows is going to be the most helpful.

Dr. Robert Boland: 28:02

So a lot of our audience are clinicians, and what we wanted to put to you, what advice do you have for them if they want to pursue this more?

Dr. Patricia Daza: 28:10

Yeah, I have two thoughts on that, and the main thing is and again, we get no kickbacks from this.

Dr. Robert Boland: 28:16

I know it, just it, just be cool. This isn't an advertisement. None of us work for the

Dr. Kerry Horrell: 28:21

We just know it works

Dr. Patricia Daza: 28:24

Unlike other places where you get credential that can cost up to two thousand dollars, like this is a fairly inexpensive training that can happen for people that want to find out more information around that. So I think that's important. I think, especially, as Dr. Lira was mentioning, in the outpatient we have a lot of opportunities for consultation and talking about difficult cases or when there's losses in different ways. An outpatient as much as people can have, or join consultation groups, small groups, to talk about this process, I think is incredibly important, because this is very, very difficult work to do kind of in isolation. So those would be the two things that come to mind for me.

Dr. Adrian Lira: 29:02

I think for me, well, education, I think, is important. That's definitely something that I would suggest to others is like Patty was mentioning get some training, get some education, get some consultation. This is heavy work and I think having a community is important. And the other part, I think it's important for us as clinicians to address our own anxieties and fears around suicide. I think if we don't address that sometimes we will skirt around the topic, we might not be as thorough, we might avoid it, and our clients feel that. They understand and they know when we're not comfortable in a certain area. So, I would say address that anxiety, address that fear, reduce that countertransference as much as possible.

Dr. Kerry Horrell: 29:45

Maybe to close this out today, Patty, you had mentioned that a patient had once kind of given you some feedback after your treatment with them and doing CAMS. I wonder if you could read us a little bit from their feedback.

Dr. Adrian Lira: 29:57

Yes, thanks, Kerry. We do talk a little bit about this in our training because I think it really summarizes why this work is important. So this was a client from many years ago, but this is part of the letter that they wrote me and it says: I found it especially valuable that you seem to recognize my strengths and vulnerabilities simultaneously. In particular, you're recognizing my willingness to talk about my suicidal thoughts and self-harm urges as a strength, allowed me to see for myself that I have been working hard in this recovery all this time and that my continued survival is a genuine accomplishment. I will always be grateful for that. And it's so true that happens here, right? I'm so moved by this because for this person to see the gains that really talking about it, this is so hard and being vulnerable, and so I just thought it was a nice kind of ending to some of the talks that we're having today.

Dr. Kerry Horrell: 30:51

I really appreciate that and again, I appreciate you both, not only for coming on talking to us but for your work here at the clinic and keeping us up to date on CAMS, getting us trained CAMS and, like you said, patty, making this actually something that every clinician who comes to our hospital now who's doing individual therapy knows. Like I think that's so cool, because I think you're right, like to not feel anxious about working with suicidality and to know that we're going to address it. I think really helps, especially our patients who come in and they are in a very low spot.

Dr. Robert Boland: 31:19

Yeah, so thanks so much for joining us today.

Dr. Kerry Horrell: 31:22

Again we've been listening to Dr Adrian Lira and Dr. Patty Daza of our very own Menninger Clinic.

Dr. Robert Boland: 31:29

Thanks for joining us.

Dr. Kerry Horrell: 31:30

Thank you

Dr. Patricia Daza: 31:30

thank you.

Dr. Adrian Lira: 31:32

Thank you

Dr. Robert Boland: 31:33

And so you've been listening to the Mind Dives podcast and I'm Dr. Bob Boland.

Dr. Kerry Horrell: 31:37

And I'm Dr Kerry Horrell, and thanks for diving in. The Mind Dive podcast is presented by the Menninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen.

Dr. Robert Boland: 31:51

For more episodes like this, visit www.menningerclinic.org.

Dr. Kerry Horrell: 31:56

To submit a topic for discussion. Send us an email at podcast at menninger.edu.