Ending the Fear-Driven Cycle in Suicidal Care

Mental healthcare practitioners often feel that it is ‘better to be safe than sorry’ when deciding on medicating and involuntarily committing their suicidal patients, potentially leading to worse mental and physical health outcomes.

A new article authored by David Jobes and Jeffery Barnett, the founders of the Collaborative Assessment and Management of Suicidality (CAMS), was recently published in American Psychologist. The article, titled “Evidence-based care for suicidality as an ethical and professional imperative: How to decrease suicidal suffering and save lives,” argues that this fear-based approach is not only unfounded but deadly.

“For mental health providers, patients who present with suicidal thoughts and behaviors are a major source of stress and concern across professional disciplines. Moreover, the abject fear of blame and of malpractice tort litigation for wrongful death being pursued by grieving families following a suicide of someone in treatment can paralyze clinical providers,” write Jobes and Barnett.

“Collectively, various fears engendered by the prospect of a patient who is suicidal compel many clinicians to practice defensively, leading to extreme interventions such as inpatient psychiatric admissions and the prompt use of psychotropic medications, with a “better safe than sorry” attitude toward such patients… Problematically, these interventions have either limited, mixed, or no empirical support for effectively treating suicidal risk.”

Jobes and Barnett’s article highlights the ethical and professional imperative for mental health providers to adopt evidence-based care for suicidality. They emphasize that while fear of malpractice litigation and professional stigma drives many clinicians to rely on ineffective and sometimes harmful interventions, there are well-researched psychological approaches that have proven to decrease suicidal ideation and behaviors. By shifting away from outdated methods and towards evidence-based practices, clinicians can better serve their patients and align with ethical standards of competence and professional responsibility. The article calls for a paradigm shift in treating suicidality, advocating for interventions like the Collaborative Assessment and Management of Suicidality (CAMS) and other evidence-based approaches.

In the realm of mental health, the treatment of suicidal patients often triggers a cascade of fear-driven decisions among clinicians. The reliance on inpatient hospitalization and medication—approaches with limited efficacy—has become a default.

Jobes and Barnett begin their article poignantly noting that close to 50,000 people in the United States killed themselves in 2022, and upwards of 2,600,000 people attempted suicide. Not to mention, 16,600,000 reported having serious thoughts of suicide in 2022. Suicides increase steadily year-to-year, with an abnormal dip in 2020.

“Given these striking data, suicide is a significant public health and major mental health concern in the United States (and around the world).”

But suicide is notoriously tricky to understand, approach, and prevent—often leaving practitioners guessing at what the next best steps might be for their suicidal patients, who are often perceived to be irrational, incompetent, and severely mentally ill. The assumption that suicidal patients are irrational and their desire to die is primarily founded in an underlying mental illness frequently misses the point, according to Jobes and Barnett. This belief that suicidal patients are also beyond the realm of everyday mental health support also aids and abets practitioners to overprescribe and involuntarily commit their patients out of fear. Fear of shame and feelings of incompetence coupled with the fear of legal repercussions from families if their patient’s suicide attempt is successful.

Notably, the authors argue:

“Treating depression with antidepressant medication is too often insufficient for reducing suicidal ideation and behaviors. There are also well-established correlation findings of an increased risk of suicide post-discharge from inpatient care… The evolving research literature in clinical suicidology is creating interventions for suicidal risk that now have decades of clinical trial research support for effectively reducing suicidal ideation and behaviors. Beyond scientific dispute, the overwhelming findings from randomized controlled trials (RCTs) show that the best interventions and clinical treatments for suicidal risk are almost all psychological and typically do not focus on mental disorders.”

And, then ask:

“Why are clinical providers across disciplines seemingly so reluctant to seek out and use proven evidence-based interventions and treatments to help decrease suicidal suffering and death?”

Jobes and Barnett seek to answer this question throughout the rest of their paper through a brief literature review. Noting first that many ‘evidenced-based’ interventions, like the PHQ-9, are insufficient to be used alone in discerning suicide risk in patients. However, other evidence-based interventions, like Safety-Planning Interventions, when used routinely within clinical practice, can help reduce suicide risk in patients.

Highlighting the Safety Plan Intervention (SPI) which is completed in a six-step format, collaboratively, focusing first on self-soothing and then reducing access to lethal means. Similar to the SPI is the Crisis Response Plan (CRP), which is also necessarily collaborative and designed to support self-soothing and reduce access to lethal means.

The authors also highlight their own Safety Planning-Type Intervention, CAMS. CAMS stands for Collaborative Assessment and Management of Suicidality. It uses a ‘multipurpose assessment, stabilization, treatment planning, tracking, and clinical outcome tool’ while also targeting and treating patient-identified drivers and triggers of suicidality.

In addition to safety-planning interventions, the authors highlight other evidence-based interventions, such as cognitive and dialectical behavior therapy, caring contact follow-up, crisis hotlines, and text lines. But Jobes and Barnett note that these interventions, although evidenced-based in reducing the likelihood of a successful suicide attempt, rarely reduce suicidal ideation.

Given the robust tools and interventions above that have all been shown to reduce suicidality or, at the very least, reduce the likelihood of successful suicide, the authors remind mental healthcare practitioners to remember their ethical principles and standards.

Particularly important is Ethical Standard 2: Competence.

“…it is stated that “Psychologists provide services…with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience” that “Psychologists undertake ongoing efforts to develop and maintain their competence” and that “Psychologists’ work is based upon established scientific and professional knowledge of the discipline” Thus, it should be seen that the competent and effective provision of evidence-based assessments and treatments is an ethical obligation for each psychologist. Applying out-of-date and unsupported interventions does not comply with ethical obligations articulated in Ethical Standard 2.”

In essence, Jobes and Barnett claim that fear approaches suicidality—overmedication for mental illness and involuntary commitment is indicative of clinical incompetence. If practitioners hope to demonstrate competence in their mental health practice, the authors implore practitioners to reduce their fear by practicing clinical risk management.

In other words, being mindful of informed consent, documentation, consultation, and clinical competence is important. All of these, when done well, will reduce the likelihood of successful litigation against the practitioner, alleviating fear and liberating the practitioner to freely practice the aforementioned evidence-based interventions.

Jobes and Barnett end their paper with a call to action, it begins:

“Suicide is a major public and mental health challenge. Fortunately, there is now a vibrant evidence-based clinical suicidology literature that provides excellent guidance for effective suicide assessment, acute interventions, and, ultimately, treatments for suicide risk. Unfortunately, these evidence-based approaches are not widely used within routine practice, and far too many mental health professionals avoid patients who are suicidal, fearing liability and even trauma should they lose a patient to suicide. This is an untenable position that fundamentally defies the ethical principles and standards of the profession. Relying on evidence-based, suicide-focused approaches is the best possible clinical risk management strategy related to suicidal risk. Moreover, given the magnitude of the problem—as a life or death issue—there is now a professional and ethical imperative for psychologists (and all mental health professionals) to change from status quo clinical practices. The field of mental health is encouraged to embrace an increased focus on the issue of suicide. Given the emerging evidence base that has been described, this focus is particularly needed among psychologists who ethically aspire to competence and the use of scientifically supported approaches.”

A concluding note on conflict of interest: Throughout the article, both Jobes and Barnett point to their CAMS intervention as a promising, evidence-based alternative to involuntary commitment and overmedication. While it is not difficult to offer better options than involuntary commitment and overmedication, each claim the authors make about CAMS is supported by peer-reviewed meta-analyses and peer review. However, it is important to note that Jobes and Barnett have a vested interest in using CAMS as an alternative to standard approaches for addressing and treating suicidality.

 

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Jobes, D. A., & Barnett, J. E. (2024). Evidence-based care for suicidality as an ethical and professional imperative: How to decrease suicidal suffering and save lives. American Psychologist. (Link)