The Psychology of Life and Suicide Prevention with Dr. David Jobes

Episode Description:

The shift from traditional risk assessment to collaborative, person-centered care is reshaping suicide prevention. In this inaugural episode of Never the Same, Professor Tony Pisani sits down with Dr. David Jobes, creator of the Collaborative Assessment and Management of Suicidality (CAMS), to discuss this transformative approach.

Dr. Jobes shares insights from decades of work with patients and offers a glimpse into the life-changing potential of CAMS: "You can find a way through an incredibly dark moment and look back, saying, ‘Oh my god, I almost ended my life.’”

Learn how this groundbreaking framework puts patients at the center of their care, fosters hope, and transforms lives.

Guest: Dr. David Jobes

Dr. David A. Jobes is a renowned clinical psychologist and suicidologist with over 30 years of experience. As a professor at Catholic University, he directs the Suicide Prevention Lab and has authored six books and 100+ peer-reviewed publications. Dr. Jobes is the creator of CAMS, a framework that has revolutionized care for individuals with suicidal thoughts.

Host: Dr. Tony Pisani
Dr. Tony Pisani is a professor, clinician, and founder of SafeSide Prevention, leading its mission to build safer, more connected military, health, education, and workplace communities.

Links:

• CAMS training for mental health professionals
• Meta-analysis Paper on CAMS
• Jobes Lab on X.com
• Dr. Jobes’ Bio at Catholic University

Transcript

Tony: [00:00:00] So I had the opportunity to interview Dr. David Jobes, who's a well-known, suicide prevention developer and researcher. It's a wide ranging conversation that covers everything from the psychology of life, from somebody who has been working on the problem of suicide, to a particular treatment approach that Dr.

Jobs developed. Also things about careers and career paths and some ideas about what's needed in, in, in mental health in our country. Hope, hope that's a useful conversation. Was certainly very stimulating for me. Dr. David Jobes is a professor of psychology and the director of the Suicide Prevention Laboratory, and associate director of clinical training at the Catholic University of America.

He's an adjunct professor of psychiatry at the School of Medicine of the Uniformed Services [00:01:00] University and has done a lot of work with veterans and military populations. He's the author of seven books and numerous peer reviewed articles. He's the past president of the American Association for Suicidology and a recipient of many awards for his work,

including the AAS, American Association for Suicidology's Snideman Award and the Dublin Award for, career contributions. He also received the Linehan Award named after Marsha Linehan, developer of a well known treatment for people who've had suicide attempts, for his career contributions.

He's been a consultant to the Centers for Disease Control and Prevention, the National Academy of Medicine, the Veteran Affairs, and the U. S. Army Intelligence and Security Command. So Dr. David Jobes is not only a researcher and a [00:02:00] developer of treatment, but also very involved in policy and advocacy, and continues to maintain a private clinical and consulting practice in Washington, D.C.

and Maryland. Before we get started with this interview, I wanted to note that I'm a professor at the University of Rochester and affiliated with the Center for the Study and Prevention of Suicide, and although my work at SafeSide Prevention and this interview is separate from that work, it's part of the same mission to develop, discover, and share resources that can improve health, productivity, and well being.

So without any further ado, my interview with Dr. David Jobes. Dave, I'm really glad that we could sit down and talk today. I appreciate you making the time to do this.

David Jobes: Of course, Tony. I'm so glad to be with you.

Tony: Just to start off, you've shared with me before that you teach a class, called the Psychology [00:03:00] of Life?

David Jobes: I teach a senior seminar where one of the classes of three in the week is on the Psychology of Life, yes. So these are our graduating seniors. It's about 80 students who are going to be graduating in the fall. And, the class is broken up into three distinct focuses, foci. The first is, the Psychology of Life.

The Wednesday class is on psychology, because they're taking comprehensive exams. And the third, class on Friday is focused on alumni coming through, the Writing Center coming through about resumes and cover letters. But the Psychology of Life class, to me, is so special because the first six classes are about suicide.

And that may seem odd, except the way that we look at it is, in studying people who are suicidal for 40 years, we've learned a lot about life, what makes life worth living, what [00:04:00] people who are thinking about exiting life are preoccupied with. And it really provides a lot of information, I think, to the students that is exciting. It also is a chance for me to describe my own journey, not in a narcissistic, self indulgent way, but to say, when I was a fall semester senior at the University of Colorado, I had no idea who I was, where I'm going, what I'm going to be doing.

I was lost. And so I start there and then I work my way through my own professional development and along the way I'm talking about research methods and I'm talking about things in psychology. So we start out with suicide and then we transition into, usually novels and different books that talk about the journey or talk about what makes life worth living.

And the students pretty much love it. They get very excited about these ideas because they're thoughtful and preoccupied with where they're going to be and what they're going to do.

Tony: Yeah. [00:05:00] What are you, what are you hoping that they're going to take from the psychology of life portion of it?

David Jobes: To be reflective, to have an examined life, to be intentional, to not just default into what's expected of them or what their parents want for them, but to really discern for themselves what makes sense, what they want to do. They're all psychology majors, and my first question in class is, how many of your parents are excited about you being a psychology major?

No hands go up, of course. And my point to them is that we can do exciting things with this degree. It's a great foundational degree. Which is why in the Friday class, we have alumni who've been in their seat, stroll through and talk about their experiences. So people have gone to law school and become attorneys.

Others took a deep dive in neuroscience. Others have gone to the military, others work in business, so that they can really see that there are different routes that people pursue in their [00:06:00] pursuit of trying to find a life with purpose and meaning.

Tony: You said that part of it, it starts with suicide and somebody who has been really devoted your life and career to preventing suicide.

What are the, what are some of the things that you've learned or the students tend to learn from looking at suicide about life?

David Jobes: A lot about what makes life worth living. Marsha Linehan our colleague at the University of Washington, has talked about that for many years, but never really operationalized it, even in dialectical behavior therapy.

We study reasons for living and reasons for dying, for example. We study what we call drivers, which are what people who are suicidal are saying compels them to consider suicide. And when we really look at that, we start to learn about what's missing or what people who struggle are yearning for. [00:07:00]And a lot of it, Tony, is relational.

The vast majority of the preoccupation is a breakup, a failed marriage, loneliness, isolation. The vast majority of both on the assessment side and on the treatment side of what we see in our clinical trials are people who flounder in the relational world, trying to find meaningful attachments.

And, and then other things follow from there. But that, relational piece is huge. And then vocation is huge. So it's, a, lens through which we can understand and think about what people struggle with. And what I think a lot about these days is that, 15. 6 million Americans have serious thoughts of suicide.

There's about 300 times greater than those that die by suicide. And so one of my agenda is to really raise our awareness that our biggest suicide problem as a [00:08:00] population is a serious suicidal ideation problem. And if we were better at identifying those people upstream and intervening with them there, fewer would go on to attempt, arguably, and fewer would go on to take their lives.

Tony: Wow. I can really relate to this idea about, in fact, one of the things the farther along that I've gotten in my own career and understanding about a full range of people who are really struggling or some people who are even doing well is just how fundamentally social and relational we are as people.

It gets brought home for me in like how we work with people in health settings, but also how successful organizations and businesses work, what it takes to be successful in your career. All of that intends to be around relationships, the network of relationships that people are embedded in and, yeah, [00:09:00] I would say that for me, that's been something that I have gotten clearer about how much of work within psychology, suicide prevention, but even broader.

We are just so, the reward of having meaningful relationships with people, so much drives us.

David Jobes: We were surprised in a study that we did in 2004, looking at reasons for living and reasons for dying. And, also different kinds of ways that we prompt and have people qualitatively describe their experience.

We were really expecting people saying my depression, my psychosis, that would be the predominant thing that they're preoccupied with. It was relationships, followed closely by vocation, followed yet again by issues of the self, how I feel about myself, or my self esteem, or my self hatred, perhaps.

And it wasn't that symptoms of psychopathology weren't there, [00:10:00] but it was not the lion's share of the focus. It was really a work-love, something that Freud talked about a long time ago, is that sort of the essential elements of life tend to center around work and love. And, that's certainly what we've seen in our populations that we study.

Tony: Given that, I know that we share some concerns sometimes about how people who are presenting to health systems with thoughts about suicide, how those concerns get addressed. And, I read in preparing for, that you, have been influenced, you were influenced early on by Dr.

John Maltzberger and I actually hadn't been familiar with his work. I'm wondering if you could, say who Dr. Malzberger [00:11:00] was and how that influenced you?

David Jobes: Yeah. Dr. Malzberger was a psychoanalyst. He passed away several years ago and it was at McLean Medical Center and Harvard.

Tony: In Massachusetts.

David Jobes: Yeah, Harvard Medical School. And he was a luminary. He was a, I feel like he's a founding father. He, along with Dan Bowie, wrote a paper in the 70s about countertransference hate and the patients who are suicidal.

Tony: Could you just, for a second, just in case people don't know what countertransference is, could you just define that before?

David Jobes: Yeah, not therapeutic feelings towards the patient.

So, he talks about, avoidance and hatred and, pretty unpleasant ideas that you would think a psychotherapist has these feelings towards these patients, but as you and I know people do, clinicians do, and so he was the first to put that on the map and talk about malice and aversion.

Tony: Talk about...

David Jobes: Malice [00:12:00]

Tony: and aversion.

Yeah, say more about that.

David Jobes: So central to his theory of countertransference was that clinicians had these malignant feelings towards people who are talking about suicide and would be avoidant of them. Try to get rid of them. And from part of your question, I think we still see that as a pervasive element in systems of care where many clinicians who see a person who's talked about suicide, they are desperate to get rid of them, desperate to get them hospitalized, desperate to not have in their caseload.

And people who are suicidal know or sense that. In fact, there's one study that came out several years ago, that some patients are reluctant to talk about suicide because they don't want to be hospitalized. So they're not talking about it because they don't want to be hospitalized. So that doesn't seem right, does it?

Tony: Yeah. Our, our [00:13:00] team here is very influenced by, it really is a, we have a theme called Better Together that people from different disciplines, clinicians, but, really working together with people with lived experience and, that's probably been one of the most of the last kind of five to eight years, for me has been, I've just learned so much from those collaborations.

And I don't think that most people who are working in health or mental health settings fundamentally have those feelings towards people. They wanna help, they care, but it's just so scary when somebody, is either coming to share that or somebody else has said that there's a, that there's a concern in that area.

And I [00:14:00] just wonder how much of that is out of fear, those feelings of, I want to get rid of, how much of that comes out of fear?

David Jobes: Probably most of it.

And I would say is there's a history to this that's quite relevant. If you look back at medieval times, the idea was, in those days before they had really treatments,

to think of a person who has suicidal thoughts, a lunatic, for example, is non compostmentos, which was Latin for not in the right mind. If God gives us life and the king is sort of God's representative on earth, then you're doing a crime against God or against the king, against the state.. So we got into a custodial model, a model where this person who's not in their right mind must be stopped at all cost.

And then this idea of moral treatment came along and the asylum movement was born in France. But [00:15:00] it was not very pretty. It was meant to be a philosophically beautiful thing, that people who are vulnerable in this way would be protected and given a kind of asylum.. But that's not how it went, and that's not what we associate with asylums.

And it created a trajectory, I would contend, that a person who has suicidal thoughts is out of control, therefore we must control them, and then when they come to their senses, they'll no longer be suicidal. And I think that notion haunts us right to the present day.

Tony: It's amazing that we'd still have that legacy.

I think another part of that legacy too, is, it was not that long ago that people who were considered high risk were put institutions for potentially their whole lives until that and although we no longer do that, it seems like we still [00:16:00] act like we should be.

David Jobes: Yeah. I think that's true. A lot of clinicians are surprised when they go to hospitalize somebody and it ends up being a two or three days stay. I'm old enough to have started in the field as a psych tech working in an inpatient unit, in the early 80s, and it was not uncommon in those days for people to be hospitalized

six months, ten months, a three week hospitalization would have been a very brief stay. Some people would stay for a year or two. Some people, as you say, in state institutions would be hospitalized for their duration of their life. And now those stays have shrunk, to very brief stays. I think the average is from five or six days and probably the mode is two or three days.

And there's not a lot of treatment going on there. So in my mind, there's a lot of magical thinking in this scenario where a two or three day hospital stay is somehow doing something that we don't know what, but it's got to be beneficial for sure. When the research shows for sure that there's now increased risk post discharge.

And as [00:17:00] this has been replicated around the world. It doesn't mean that the hospitalization causes suicide, although some argue that. Our friend Matthew Large in Melbourne, Australia, talks about nosocomial suicides, which are suicides he contends are caused by the hospitalization.

Tony: What's the word?

David Jobes: Nosocomial.

Tony: Nosocomial.

David Jobes: Yep. Fancy word. And Matt feels very strongly about it.

Tony: Yeah.

David Jobes: I don't know if it's that clear, but I do know that there's definitely significant data, significant correlational data of an increased risk in the week, weeks, year, even a lifetime from a single hospitalization. And to me, it's not a statement to be anti-hospitalization as much as it is we really need to become much more focused on suicide because it's not necessarily the case that people get a safety plan.

Or people, there's a discussion of lethal means safety, or there's a discussion of family about disposition, or any caring contact, or things that, that the research shows could be low [00:18:00] hanging fruit for helpful interventions. It's not automatic, and oftentimes it's not done.

Tony: Wow. I read that, that you said, I, and we can't, believe everything you read on the internet, but, it said that, I think the greatest challenges are ones of our culture

and our mindset about what's most helpful to suicidal people. I think we've got a mindset that a suicidal person belongs in the hospital and that you help them by treating the mental disorder. Could you expand more on that challenge and how you see that playing out?

David Jobes: I think a lot of us were raised in a DSM kind of world, Diagnostic Statistical Manual here in the States, or the ICD.

Tony: That's a kind of a categorization of different disorders and what defines them.

David Jobes: Right, and the [00:19:00] common thinking, certainly when I was first in the field, was that people who are suicidal are depressed, so suicide ideation and behavior is a symptom of their depression, or they have schizophrenia, or they're bipolar, manic depressive disorder, and the symptom of suicidal ideation and behavior.

And the research doesn't really bear that out, so the idea that you treat the disorder to get rid of ideation and behavior is not really, reliably supported by the literature. There are exceptions, but what I would say, or argue, is that most clinicians do believe a person who's suicidal belongs in the hospital, even for a very brief stay.

And the, and basically the only treatment they're going to get is medication. And as I've alluded, medications, with some exceptions, are not necessarily helpful with suicidal ideation and behavior. They can be helpful with psychosis or anxiety or other kinds of symptoms, but not necessarily for suicide.

And so a lot of people [00:20:00] think, oh, they need to go to the hospital. They need to get medication on board. We got to get that started. When there's not much evidence to support that model. And I would say that's probably the modal response of many clinicians. And yet there are evidence based interventions that you're aware of that are not widely used.

And that disconnect is something I'm very preoccupied. Yeah.

Tony: Yeah. And I want to talk some about those evidence based interventions in a minute, but I just want to dwell on this a little bit longer because one of the things that I feel like I'm seeing is that, I would say most, maybe I'm overstating it, but I think most of the, kind of staff and clinicians that I interact with, are actually pretty skeptical about

what the hospital will do, especially for people who don't want to be there. There are some people who [00:21:00] really want to have that kind of refuge. And I think it's important that we make those more humane, have more, you know, support that people are looking for. But, I think a lot of people are sort of woken up to this is not gonna, this may not solve things, it could make some things worse, but they feel caught

David Jobes: They are.

Tony: in a system that, where they're worried, a system that sort of almost puts them in a bind, where they're worried that, well, if some action isn't taken, that's, you know, takes the control from this person, that they're going to be blamed, either by themselves or other people. And so I think there's, I'm worried about this disconnect between people feeling like, yeah, I think this person, I can really support this person, [00:22:00] but I have a, another set of obligations and within the system. What do you think?

David Jobes: Yeah, we start with fear and this idea of countertransference and these not therapeutic feelings that clinicians can have. A lot of that is rooted in the fear. And the fear is that if I don't do everything, the kitchen sink, so to speak, a defensive practice, and this person goes on to take their life, I'll be sued by the family for malpractice, wrongful death, tort litigation.

Here in the United States, that's a very big preoccupation. It's actually fairly rare, but the level of fear and anxiety that clinicians have about being sued for malpractice is disproportionate to the reality, but it makes clinicians paralyzed. And as you say, Tony, a lot of people are engaged in systems of care where they're not feeling great about the care, quote on quote, that's being rendered.

It's a very brief stay. Utilization review shows up and says, patient's been here for three days, get them out the door. [00:23:00] And it feels premature. And when you're my age, you can look back in the days where we would have a patient in a unit for a month, six weeks, and they were doing really well in the milieu of the therapy, the therapeutic environment.

They'd go on pass that weekend for an hour. And if they did really well, they're go on a pass the next weekend for two hours, and so they would work their way out of the hospital and their disposition, where they come out the back end of that is very different. In a three or four day hospital stay, they're no longer in the workforce, they're pulled out of school, now they're officially a crazy person because they've been to a psychiatric hospital, and they probably are coming out not feeling a whole lot better many times.

And so my goal is to not bash inpatient care, it's to make it better. And there are simple things that could be done to raise the standard of care, of inpatient care, but it's against this tradition.

Tony: Yeah. [00:24:00] So, that's interesting. I'm interested in your ideas about that because, I know a lot of people, very skilled and compassionate people who work in inpatient units, and I think they would be interested to know, but they're not, you can't change the entire system.

They can't change the insurance system. Or maybe they can. I'd be interested to hear your thoughts about that. But what do you think they can do, to improve that experience and also maybe for themselves to feel like, I'm contributing to, kind of,

making this better?

David Jobes: I was on a task force founded by the National Action Alliance for Suicide Prevention.

And the task force was to design recommendations for standard care. For inpatient care, outpatient care, emergency department, different settings. And we identified [00:25:00] just some very basic ideas. That you would screen or identify someone at risk as routine care. That they would get a safety planning type intervention during the hospital stay.

That they would learn about the National Lifeline, the National Text Line, as resources. That there would be discussion about lethal means safety, you know, about firearms or medications in the home. That there would then be possibly caring contact, after discharge. There'd be phone calls or, a letter or different kinds of ways of reaching out.

Each one of those interventions, not expensive, fairly easy to do, doesn't require extensive training. And has evidence in support of those approaches. So that to us was like the low hanging fruit of what could be done. And, and yet it's not normal. That's not the norm.

Tony: One thought, set of thoughts that I've [00:26:00] had is to draw, to learn from, treatments that exist, like the ones that you developed and we'll talk about in a bit. But, we've been really trying to learn like what are some common characteristics of treatments that work and even in places where those treatments aren't happening or wouldn't be part of somebody's role, that they could maybe draw on those.

So as one example, I know in the Collaborative Assessment and Management of Suicide Risk, which we refer to as CAMS, you have an interesting starting point, of that, of that treatment, even in terms of how people position themselves. Could you share about that?

David Jobes: In the Collaborative Assessment Management of Suicidality, which is much easily,

Tony: Of suicidality.

David Jobes: It's, CAMS is much easier, we really try to engage in the topic of suicide very [00:27:00] quickly, either through the use of a screener or a listening ear for somebody who's dropping hints, to engage within the first five to ten minutes.

A lot of times, as you know as a clinician, you'll get a referral specifically because there's concern about suicide risk. And in CAMS, we just go right into it. We don't chit chat, we don't spend a lot of time with mental status and things, we dive right in. The really key part to this is to say, we want to understand what it's like to be you with regard to suicide.

To do that, we have an assessment tool, that we complete together, if that's okay. And actually in the standard administration, I take a seat next to you, if that feels okay, and we go through this together.

Tony: That's just right there. So in other words, potentially if I'm a, a nurse, even on an inpatient unit or in a community setting, some of that are things that I could draw from.

[00:28:00] Because, so I could, do two things I heard you say. One was you're asking permission.

David Jobes: Absolutely.

Tony: The other is you're asking permission to sit alongside. Those are things that actually wouldn't take a lot of extra time. And, because one of the things that's so hard for people is that, there aren't, units are understaffed and things like that, and that's true.

Inpatient, outpatient, community, there always feels like there's not enough time. But asking somebody's permission, there's a set of questions that, you know, and a tool that we use to try to understand what it's like to be you with these thoughts. We want to understand more about them. And to do that, like if it's, you're comfortable with it to sit next to you to do it, it doesn't actually take any more time to do that than it would to say, start spewing off

David Jobes: Risk factors.

Tony: Or, a screening instrument.

Because, [00:29:00] I know that I have to do that. It's, in my, and it's probably a good idea to have that, but, but, we have a saying, this is again, one of those things that influenced by our lived experience team, you know, what you do matters, but how you do it matters more.

David Jobes: Yeah.

Tony: And in, in this case, I think we can learn from approach.

here's, say ba basically I'm doing a, little evidence-based mini practice

David Jobes: yeah.

Tony: by sitting next to a person and I, while it's simple, I don't know that most people have tried that.

David Jobes: No. I'll tell you one thing that's makes me chuckle is that I've had nurses and social workers say, "Well, you're just talking about good nursing, it's what social workers do all the time".

You've never, you haven't discovered anything new and I didn't claim I did, but I do think, it's very important to impress upon the client or the patient. That I want to understand [00:30:00] what it's like to be you. I want to see things through your eyes. The inspiration probably for this was the Rorschach.

So the Rorschach inkblot test is, as you know, is a controversial and also venerable assessment tool that's been used for decades, and I used to teach it, when I was first hired at the university. And the Rorschach, you sit next to the patient

and you, give them the 10 cards that Hermann Rorschach in Switzerland developed a long time ago.

And they see what they see. They don't look like anything, but they see what they see. And then there's an inquiry. And the inquiry is a really special thing because the clinician's literally hanging on every word of how they see, what they see, and why they see it. And that's how you score the test. And that metaphorically is what we do in CAMS, is that we have an assessment tool, but it's more than that.

It's a stimulus field of different quantitative and qualitative [00:31:00] responses that the patient actually does in their own hand. Now we have a modified version of this to do it in telehealth, but the goal of having the patient do this, and I'm sitting there working with them and clarifying things, takes about 20 minutes.

But what you've earned in 20 minutes is that they're not being judged. This person's interested. They get what I'm describing and putting down. They are not, wagging their finger at me, they're not scowling at me, they're just really trying to understand. So there was a meta analysis that was done a number of years ago with one of our early CAMS clinical trials that showed the assessment aspects of the intervention where therapeutic was a therapeutic assessment.

Because the idea that you're empathic, collaborative, non-judgmental, patient centered, you know, I know, people with lived experience will tell us that's what they appreciate and need and want. And that's not necessarily what they get in the emergency department or in an inpatient setting, or even an outpatient [00:32:00] clinician who's maybe quite sophisticated, but doesn't really know the difference in this kind of dynamic we're talking about.

Tony: That's so interesting. I didn't realize that it had sort of come out of, The Rorschach inkblot idea, which, really is probably not used very much, probably not taught very much. It was still being taught when I was in graduate school. And I do actually, I can remember what you're saying of, maybe not so much as, did what people saw really tell you about their pathology?

I'm not sure. Yeah, was never really sure about that. It was really nice to just sort of listen and there was no wrong answer.

David Jobes: No.

Tony: Sometimes, now a situation like that can, sometimes can make people anxious. 'Cause like what are you trying to do to me here?' And now like where this is, where you've evolved it to,

it's like, it's very transparent what we're trying to do here. So there isn't that kind of "woo woo" feeling to the ink blots. But, but it's, just interesting. I think this is one of the things that, I, [00:33:00] feel like is, taking something from one place and applying it to another, I, I really think is an important path forward when we're trying to work on a really hard problem.

And, so it's so interesting that you would, imported that insight into, into CAMS.

David Jobes: I, have a. Going back to Dr. Malzberger, who went by Terry, for those who knew him. Early in my training, I was in graduate school. I went to a conference where he was presenting a videotape.

And I had read his work and was a big fan and super excited to see him in person. And the video was fascinating because it was a extremely dysregulated young woman, who was diagnosed with borderline personality disorder and had made some very impulsive self harming and suicide, frank suicide attempts.

And he comes into the room and looks at her and sits down in the adjacent chair and then turns his chair away. [00:34:00] So they're side by side, but that, turns the chair away. And then he starts asking her questions and he's picking lint off his tie. Yeah. And I was like, what the heck? And he seemed like distracted.

And then she would say her thing and then he'd say, and then he'd look over and, and this whole interview went on along those lines. And I thought, I walked out. I was like, what the heck? He's not even dialed into her or focusing on her. And then wouldn't you know, several years later, he was president of this association.

He wanted me to be his program chair and we got together and for dinner and, and we got to talking and I, so Terry, what was this?

Tony: What was the deal?

David Jobes: What was the deal? And he's from Texas. And he would say, he looked at me and said, "Why David, wasn't it quite plain that she could not withstand the intensity of my gaze?"[00:35:00]

And I was like, what? He said, he evaluated in the first few seconds of seeing her that she might be overstimulated by him, bearing down and really looking at her. And so he made that adjustment and he said, and do you remember what she said? I said, oh, she opened up like a book.

She told you everything. He said, that was the point.

Tony: Yeah. That's really interesting. I, we, I just, we were just holding some listening sessions with people about alternatives to, current options for crisis care.

David Jobes: Yeah.

Tony: And one of the things that really stuck with me from this, these sessions where we were hearing people's experiences and what they're, was that one person said, "I wish there was an option where I didn't have to talk."

And, and [00:36:00] there's this expectation that, in order to get support, you need to sit down across from a person and, they're going to ask you questions and you have to answer them. And, that was very, it was very eye opening. I wish there was something where I didn't have to talk. And he's some things that have helped me is, breath work or physical things.

And, I, think it just really, this sort of, lint example just reminds me that we have so many assumptions based on how we've kind of evolved as a field and so much of it is about, the person being able to articulate things. And it's like a ticket, it's like a ticket of entry because I think one of the things that either he or somebody else in that group pointed out was, and if I don't talk, I'm either [00:37:00] uncooperative,

David Jobes: resistant,

Tony: or somehow pathologized.

Like what I'm, my inability to talk is a disorder or something like that and, it can't just be like, that's not my mode. And it really seems like having a, the requesting of permission to do things, that we do things with people and not to them, and then to say, being very transparent about, this is a tool that we use, the, the Framework that we, teach at SafeSide Prevention often involves, looking at, like a diagram together.

David Jobes: Yeah.

Tony: And one of the things that I've noticed this does, and I wonder if this, how this works in CAMS. One of the things I think it does is also, you can never completely, [00:38:00] you know, pretend that there's not going to be a power dynamic. Probably there is, but I think it does flatten the power dynamic a little bit because it's not like I have some thing, I go, you know a Wizard of Oz thing, I go behind there and then we make thoughts and decisions about you or, and then present that.

It's like, this is how we think of it. Now, you can object to how I think of it. We can, and I'm testing out with you. Does this match you? But it's right there.

David Jobes: Yeah.

Tony: I wonder if that's part of

David Jobes: What I would say

Tony: mechanism of action in CAMS?

David Jobes: What I would say is that we pull back the curtain.

Yeah. I'd love the Wizard of Oz illusion, because I think that's exactly the case, and we are very transparent so that the pillars of CAMS are empathy, collaboration, transparency, and honesty.

Tony: Empathy,

David Jobes: collaboration,

Tony: transparency,

David Jobes: honesty and transparency, and then being suicide focused. [00:39:00] So that's our agenda, and when we go through the SSF, the Suicide Status Form together, which is the assessment, treatment planning, tracking tool that we use, it's very clear what I'm after.

I'm collecting this data. They actually get copies after every session of their Suicide Status Form, and the patients find it very validating, and, and when we get to the treatment plan, we say you're a co-author of your own treatment plan, we, after we get through our stabilization plan, what are the two things that make you want to kill yourself?

Which, to me, is such an obvious thing to ask a person who's suicidal, why and how are you suicidal? And then they tell us, and we call those drivers, and that's what we target and treat in CAMS. So it's a very simple idea, it's very patient centered. But, exactly, it's meant to pull the curtain back so this is not a mysterious thing that's happening.

You are an active collaborator within your [00:40:00] own suicide focused care.

Tony: Yeah. I'm really grateful for the, learning that term from you. I don't know if you invented the term drivers or not, but I think you've certainly brought it out because, in those kind of, kind of minimum standard care and we can, we'll make

available the document that you were referring to with standard care, which I think is an important advance in the field. A lot of, what I think what people think of, what do you do if you're working with somebody and you want to support them who's, thinking about ending their own life,

the first thing people will say is, safety planning. I think a lot of people would say that, and a safety planning or crisis response planning or safety planning type, interventions, are, we've been shown to [00:41:00] be helpful, but most of them are around, what will you do when things get worse, or how are you going to, prevent a crisis from becoming more dangerous?

And that's important. And I think we have more evidence for that now than we have, than we've maybe ever had. And I'm interested in kind of some of the innovations that you're doing in that area. But I think there's a real missing piece though, is like, what about what's making me feel that way? And I'm often struck.

And so actually in our, in our, Framework, the, there's a, one of the things we talk about is there's a core task of suicidary is to Respond well, that your assessments are only as good as the response that you make. And we list these four categories, but, and that's just one [00:42:00] way of formulating things.

We didn't put like, planning for safety as first because we really want to meet people about what's making you feel that way? And may, and maybe in that there's something that, some change that we could help support. And yeah, then let's make sure that we also have these, you know, potentially life saving plans in place.

Absolutely, but let's not forget about

David Jobes: the cause.

Tony: Yeah. Yeah. Yeah. How did you kind of come to that, that realization? Tell me about how that works in CAMS.

David Jobes: It was the evolution really of a, of an assessment. The Suicide Status Form started out as an assessment and we learned a ton about who, what, when, where, why, is someone thinking about suicide?

[00:43:00] And then it was Marsha Linehan who pulled me aside and said, this is great, but what we really need are treatments. And a safety plan is not a treatment. It's an intervention designed for acute risk. Arguably it's designed to re-engage the prefrontal cortex when the limbic system is over activated, which is very valuable because when we get upset and dysregulated, a lot of that happens here in the brain and we lose prefrontal cortical control.

So safety plan type interventions re-engage that part of the brain to down regulate, and that's really good, but that's not treatment. So it really was an evolution, with some of my collaborators, Kate Comtois, Lisa Brenner, Pete Gutierrez, Stephen O'Connor, what we call the CAMS Brain Trust, that to think about, how does all this evolve?

And when you assess a lot and know a lot, [00:44:00] then you're in a position, as we are in CAMS, to say, "Tony, I'd like to keep you out of the hospital, if possible, but to do that, we've got to develop a stabilization plan, which talks about lethal means safety, things that you can do to cope, how to not isolate yourself, to make it to therapy, to, you know, work on this issue."

And when that stabilization plan is in place, and feels solid, especially if lethal means are secure. Then we go back and say, "Okay, what are the two problems that make you want to kill yourself?" And, and those things are remarkably treatable. We may not eradicate every, we may not, if your spouse just left you, we might think of couples therapy, but it might be that you have to mourn the loss of that relationship.

And there are many interventions that we can use for drivers. But in the evolution of our research and moving into clinical trials, we started to toy with this idea [00:45:00] of drivers. And then the idea of being non denominational, which meant, you could be a behavior therapist, you could be a psychoanalyst, you could be whatever theoretical orientation or style that you choose, but as long as you're attacking and treating the drivers the patient articulates, then you're doing CAMS.

And so that, we move from assessment to obviously acute intervention, and now really a treatment that's supported by multiple randomized control trials. Where treating drivers actually makes a difference and people can recover and become significantly less suicidal in six or eight sessions.

Tony: So I have a lot of questions about that because you, really, you hit on a number of things that I'm really curious about.

So I'm not sure exactly the order we'll go in, but, maybe just first, I've learned over time [00:46:00] that, in different, not just different parts of the world, but in different pockets within different parts of the world, there's different ways of saying things that, and I've been of the opinion that, and I think this is borne out by like treatment adaptation research, where you take a particular treatment and then you adapt it to a different culture or population.

It seems like those almost always retain their power when you change the wording. I'm curious about in, within CAMS, what your feeling is about people adjusting the wording to match the people that they're talking to. So for example, words like, stabilization, or even what makes you want to kill yourself in some settings, being that direct would be exactly what's transparent and honest in other settings that might [00:47:00] feel, or cultures that might feel confronting.

So I'm wondering, what, as you, I know you've worked all around the world as well. What is your feeling about adjusting language?

David Jobes: It's a great question. And what I would say is one of the things that distinguishes CAMS is that it's a framework. So as a framework, we're less rigid about what you have to do in terms of treatment.

It's a framework within which there's a lot of discretion for the clinician to do things that make sense to them. And I've got a zillion examples of that, but, but a lot of that's very culturally relevant. So for example, I did training in New Mexico, with the Navajo and very conscious of being the white man from Washington, training

these indigenous American clinicians. And [00:48:00] when I got to the treatment planning, I said, you could identify the drivers with the patient after the stabilization plan is established and then treat the drivers with whatever makes sense. Ritual, native medicine, chanting. Sure. Yeah. Whatever makes sense within your culture is totally fine.

So that was, for them, great to hear because it, because there's more than one way to treat and that, I think, has been a distinguishing feature of CAMS that we can, you know, incorporate different methods. It doesn't have to be just one way.

Tony: Yeah. And what about the language aspect of the kinds of questions or the wording of things?

How do you, kind of, when questions come up about, you know, words, specific words that, that might, might seem like they're innocuous, but they, feel there's not a, [00:49:00] when people try on the words, it

David Jobes: doesn't fit.

Tony: It doesn't fit.

David Jobes: Doesn't land well. Well like you, we've been working with people with lived experience conducting qualitative interviews.

And I remember one woman that we talked to, somehow state, safety planning came up and she said, "Oh yeah, I hate safety planning." It's like, why? And she said, "Well, I need for you to be safe for me. It was a, it was like a pejorative or paternalistic. And I said, "That's not how it's intended." She said, "I know that's not how it's intended." But my feeling was, the message was you're gonna screw up.

So when you do, here's what you do. You lose her. And I was thinking, gosh, that's not what was intended when Barbara Stanley and Greg Brown developed the safety plan. And I said, "Well, how do you feel about stabilization?" She said, "I could aspire to stabilization." So I'm not saying that safety planning is wrong, but it just goes to the point that different terms land differently with different [00:50:00] people.

Tony: And it might be that for another person's stabilization, because you're not, because it seems like, I do think there are fundamental things about being human. I think there are some fundamental things even about, about suicide that are cross cultural. And I also think that I've, that the, that specific words are hardly, hardly are universal.

So they, they do need some adjusting. And it sounds like you've done that with this idea of instead of calling it safety, you call it stabilization. Maybe somebody else might, if that term doesn't work, might use, might substitute it as long as they have the fundamental idea that we're wanting to, you know, kind of, make sure there's a kind of a safe base.

David Jobes: Common ground.

You know, the field has evolved to a point, Tony, as you know, where now words do matter. So for example, we don't talk about means restriction. We talk about lethal means [00:51:00] safety. We don't, we shouldn't talk about guns. We should talk about firearms because people have done research showing that people that own firearms are less reactive and feel that guns or restricting means is very personal to something they feel is a right of theirs..

So these nuances actually matter, and thankfully our science is evolving to a point where we're able to discern some of these things that matter and change and modify some of our language. The most obvious one is like committing suicide, which again, goes back to the medieval mindset of, this is a crime, and actually it's a person struggling and suffering and not knowing what else to do.

The idea back in those days that you would put to death someone who attempted suicide, feels peculiar. So it, there are these historical roots that I find really fascinating. There's a lot in our history that matters that we don't, in my view, focus on sufficiently to understand the present day.[00:52:00]

And I love history, I love looking at the asylum movement, or even the physical asylums, the Kirkwood models that exist in this country. They're fascinating, and the histories are fascinating, and what was done in the name of care is fascinating. And I really do believe it was predominantly good people trying to do something.

Because they were desperately concerned and didn't know what else to do. But now we look at it as barbaric treatments.

Tony: Yeah.

And maybe hopefully in another period of time, we'll look back on what we're doing now and see where it's come from. Another part of this I wanted to ask you about, is about risk assessment.

So you mentioned before Matthew Large, who I really admire. There's a number of other colleagues, and, who have all really, [00:53:00] moved away from this idea of risk assessment. I think some of our work has been part of moving away from that, although we've retained some of that language here and there.

David Jobes: Yeah.

Tony: But I'm just wondering, because I think that's, especially for this is going to be a little bit inside baseball, as we say here, right? This could be a little bit technical, but I do think that there's a certain, subgroup of people who might be watching our conversation who, wonder about, ideas about risk assessment.

So could you talk about what concerns you've heard about that? How you, how CAMS addresses risk assessment, and just maybe what your thoughts are.

David Jobes: Yeah. Lots. When I was first in the field, I saw George Murphy, who's a psychiatrist, present at a conference. It was probably in the early eighties, and he said, we'll never be able to predict suicide.

It's just not going to happen in our lifetimes and maybe ever. But people who are [00:54:00] suicidal are not all the same. And he wasn't the first, but some of this dates back 50, 60, 70 years of thoughtful people saying we're not going to predict future suicidal behaviors. It's too low base rate from a purely statistical perspective.

It's very tough to predict something that's fairly rare, concerning when it happens, but very rare. And so to me, the recent hubbub about this idea has been fascinating because I feel like we've known this forever. And in the critiques of especially low, mean, and high risk, this idea, that is misleading and you're predicting behavior that we can't predict.

That's never how it was meant. David Klonsky, our colleague and friend, talks about this as a red herring that distracts us from the main event of suicide prevention, especially clinical suicide prevention. No one's saying that we're going to prevent it. We're saying that people that we see clinically are not [00:55:00] exactly the same.

It's not a homogenous population, it's heterogeneous. There are people that you're extremely worried about, and there are people like, we're good, I think it's going to be okay, and then everything in between. In an earlier version of the Suicide Status Form, we had a progress note page, mental status and diagnoses and things like that, case notes, and then when it came to a judgment, a formulation, we had low, mean, and high

risk concern. Of course, the folks in the UK and Australia and elsewhere, op eds all over the place, thoughtful people, we're really eschewing this. So, in the most recent revision of this, I've completely sidestepped and we're talking about a clinical formulation of a clinician's concern about relative stability.

And if you're my patient and you are highly dysregulated, [00:56:00] your drinking is out of control, you've got multiple lethal means at home and you're like looking at the door like you're going to bolt, I'm very concerned, extremely concerned about your stability. And even me, I might consider hospitalizing you.

I don't hospitalize patients, haven't probably for 20 years because I can tolerate a pretty high level of risk on an outpatient basis. But even with me, I would think that this might be a scenario where an inpatient hospitalization might be warranted. That's a very different kind of person than a college student who has no suicide attempts in their history, is thinking about this for the first time, is frightened, but also intrigued.

That's somebody who'd probably be handled readily on an outpatient basis. This case conceptualization model has been something that we've Keith Houghton and Mort Silverman and other thoughtful, Greg Carter, other people that we know have been endorsing, and I feel like [00:57:00] I've always been on this train, but now we've sidestepped in talking about relative stability at five levels.

We can think of the clinician's concern. And you and I were trained to have conceptualizations of things that are important. And that is your judgment, my judgment, and a defendable thing from medical legal standpoint because the bottom line is from a duty standpoint, at least in the U.S. and elsewhere, is this person imminent danger?

Yes or no. It's not like a rheostat, it's a light switch. Are they or aren't they? And of course, that's a very difficult thing to discern. Lawyers and judges don't know what it is, clinicians don't know what it is, but that's the bottom line that we're held to. But I think a conceptualization or formulation of relative stability is a sensible way to sidestep with no illusion of predicting future behavior.

Tony: Yeah. Yeah. That's interesting. Yeah. My, so I've, I'm, very sympathetic with the [00:58:00] concerns that, that talking about risk, especially in a high, medium and low setting is a red. And, and I think unfortunately it's very difficult for people who really want to support somebody in the way that they want to be supported.

It's very difficult for somebody to say, besides the fact that it's not probably reliable or predictive or all that, but it's very difficult to say this person's at high risk and continue to support them in a voluntary, collaborative, outpatient way. I think that can be really hard in the systems that we have.

And so I'm, sympathetic with that. And I, but I do also understand that we probably still need some way to express like the level of concern. It's almost it, maybe it's about, stability, but I think in a way it's sort of like, how do [00:59:00] we just convey the sort of, amount of concern maybe in relation to other people who are supported in this kind of setting, or the amount of concern in relation to where this person has been in their past?

So, so it's, I think it's a, I think it's a challenging thing. It's almost like we're in a transitional time. And, but I have to say myself, I you know, depending upon which side of the bed I wake up on, sometimes I'm like, do we need that additional abstraction at all?

Or can we just sort of address those drivers or things that are, that can be, things that are modifiable? Can we try to identify those and address them? Do we need that way of summarizing it in a little? You know, I kind of go back and forth.

David Jobes: I do too. I'm pretty sanguine about this particular approach, at least for the [01:00:00] time being, because we are always after modifiable

drivers, risk factors, warning signs.

Tony: That's the core.

David Jobes: Yep. That's the core. That's what the treatment is. But I'm not comfortable saying there's no differences. I feel like some of the critiques have kind of, not had a remedy or a clear, it's fine to critique that we can't predict future behavior.

Do you have equal concerns about every patient that you're seeing? There's gotta be some discernment of someone that you're more concerned about versus someone you feel like they're okay. They can be appropriately treated on an outpatient basis. And that I feel is the missing piece to the conversation.

I think it's coming around now with this idea of clinical formulation. Malzberger was talking about that 20 years ago.

Tony: Yeah. Yeah, interesting.

So the other part that I'm really, interested in what you shared is about addressing those drivers. And, [01:01:00] so

some drivers are probably more easily resolved or helped, or maybe we know more about how to, they're more, or if somebody in a different language might say there's more modifiable things and so let's focus on that. How does the degree to which a driver is modifiable or not, how does it influence what drivers are selected and how you focus?

David Jobes: One of the things I would say is it depends. In the, we have five , five randomized control trials right now that are funded by different, NIMH and the VA and so forth.

Tony: The National Institute of Mental Health and the Veterans Administration.

David Jobes: Yeah. And so one of the things that we're seeing, for example, with college students and teenagers that we'd never seen before are social determinants.

A, [01:02:00] a case of a woman for Africa saying racial and gender oppression, a college student saying the earth is dying, another college student saying I'll never be out of debt. I, we can't treat those, those are, we can't flip the worlds.

Tony: Right, we can be part of trying to help those things in our own advocacy efforts, but in terms of the role that we're particularly in in that moment.

David Jobes: Exactly.

What we've seen in the trials though, Tony, has been really interesting is that we don't have to eradicate or completely transform those things. We just have to make a dent in them, so to speak. Through insight work or through behavior activation or through, just reflection and meditation, whatever strikes the clinician as being a way to go after this.

And that how CAMS works, the secret sauce, [01:03:00] is not eradicating every vestige of a suicidal thought, every feeling, every cognition. It is taking this issue and shifting it and the way that I look at it, just in incremental ways. So that around the 5th or 6th or 7th session, the person is saying, you know what, I can manage the thoughts and feelings as they come up.

I have a stabilization plan, I see that there are things I can do, I have a hope kit on my phone, there are different things that I have, and I'm feeling pretty stable, behaviorally. And in the intervention, if you have three consecutive sessions, where your overall risk is lowered, and you're managing the thoughts and feelings and you're behaviorally stable, CAMS comes to a close, and that has held up well across the RCTs, the randomized control trials.

That, those criteria have held up well. And we have some [01:04:00] relapses, but not a lot. Especially for people for whom suicide is new. If they've been suicidal for 20 years, 30 years, it's not that CAMS doesn't work. It's that other treatments might work better or a combination thereof might work, but for people for whom this is like a new idea, we can get rid of it or change it significantly.

Five or six sessions. It's, it doesn't have to be this super deep dive.

Tony: Yeah. That's really helpful distinction. I appreciate that. Could you help me just picture, and now I've had some workshops and training with you. So I have some idea that was just to give people a sense of what those later meetings look like, right?

So you've had an initial, we're side by side, we're looking at this, and I guess you continue to do that, but how [01:05:00] alike or different what I see in the fourth and fifth of those meetings? What do those look like? How similar are they to one another?

David Jobes: Sure.

Tony: Share about that.

David Jobes: Three phases, there's the first session was a pretty deep dive, pretty labor intensive to get things rolling.

Then we have what we call interim care and interim care are the sessions between the first and the last. And last is called outcome disposition.

Tony: Essentially what, CAMS is doing then is, creating a container, you could say, for, for different kinds of treatment and interventions to be applied based on what the person's driver is.

So there's still a need to understand, to be able to apply these other things to those drivers.

David Jobes: Yeah.

Tony: But we're establishing a relationship, a true alliance that's based on permission, collaboration and coming alongside and [01:06:00] focusing specifically on suicide, transparently and honestly, and that kind of sets up then, different, a whole host of different ways that people might have to address those drivers.

Is that a fair representation? Corrected?

David Jobes: No, that's exactly right. I, what I would say is that Carl Rogers talks about optimizing the conditions for change. So in that first session, we're doing a very deep dive, understanding who, what, where, when and why are you suicidal? We're developing a stabilization plan to get you through your dark moments.

We've identified two problems that probably need to be treated to reduce your risk. And that's what we're going to pursue in these interim sessions. Now, as an aside, we have a study in Louisiana at LSU with Ray Tucker's group, where they're just doing one session. They're just doing that first session of CAMS on an [01:07:00] inpatient unit, and we've seen pre post change, just with that one deep dive.

But in standard CAMS, we're mostly spending the next several sessions really focusing on these drivers and crafting the stabilization plan. And patients like it, clinicians like it, it's cost effective. So there's all this clinical trial research we've done for the past 20 years that, that something happens there within that framework.

So I like how you say it's a container. It's a framework that contains the issue. The main charge to the patient is let's try to keep you out of the hospital. But to do that, we've got to develop a very solid stabilization plan, we've got to secure lethal means, give you things to cope.

So there are five different coping strategies, and then here's the national lifeline, national text line should you get in trouble, here's my cell number, which is what I do when I'm intervening this way. And we'll just go after the things that make you want to kill yourself. [01:08:00] And, and when it works, when the light bulb goes off, the patient's like, "Oh, I don't have to do this."

We had a soldier in our clinical trial at Fort Stewart who was terrifying. And my concern was that he was going to kill himself, but also take out a number of members in his unit, including his commander. By God, he really got better. And by session eight, he's like, "I'm in the Humvee. We're heading to suicide.

There's no off ramp. That's where this, that's where this journey ends." He said, "And then we drove up alongside and I'm looking at my side window here and now we've passed it. And now it's in my rear view mirror. I see it, but we're driving away." I'm like, oh.

Tony: Must have been very gratifying to hear that.

David Jobes: Yeah. And he said, "Now I'm looking for, I'm now looking to make a turn." [01:09:00] Because especially for soldiers, okay, it's a new mission. The mission is not to kill yourself. And then, but what do you do instead? So that's where in the most recent edition of the book, I've been talking about a post suicidal life, or lessons in living, or my interest in the psychology of life.

What can we offer someone like this whose life is a mess, but who gets that killing themselves is not the way to get their needs met? And so the back end of CAMS, very much focused on reasons for living, what will make their life worth living, plans, goals, and hope for the future.

Tony: Has that been a kind of evolving direction?

David Jobes: It has.

Tony: Yeah. Yeah.

David Jobes: I mean, that's the nature of research, right? We start out, this is an assessment. That's all it is.

Tony: Yeah.

David Jobes: And then we backed into this sort of model, and Marsha pushed me and discovered this idea of drivers and stabilization planning, and really the third [01:10:00] edition of the book in the series is about this back end.

What happens when this goes well? What does it look like? And how do people who think this is the way I'm going to cope and get my needs met. When they move to a place where like, okay, I'm not going to do that, but what do I do instead? So, that is a, I'm obsessed with that idea. That, I'm really thinking a lot about what would give this person who's got a truck he can't afford, who's got two or three children by three different mothers, who's being deployed again, whose life is objectively a dumpster fire.

But they're good. They're good from a CAMS standpoint because they've decided they're not going to kill themselves. But then the question is, how do you live? And so we, on the back end of CAMS, that's a big focus is trying to develop plans, goals, and hopes for the future.

Tony: So Dave, this has been, yeah, really interesting to hear about [01:11:00]the way that CAMS, the, unfolds for between, two people and, the fundamental values of it, how it works.

I know that there's been, you've engaged in a lot of research. Maybe, maybe more actual if you have numbered the trials than many other approaches have. Could you talk about what you've learned from the research that's been conducted over, I don't know how many years, about CAMS?

David Jobes: Sure. So, it's been decades really, that we've been studying the intervention, the evolution of it as well. And it began in the 90s, and it's very much [01:12:00] effectiveness research. It's not efficacy based research, which for people who don't know the differences, it's much more about the real world versus an ivory tower approach that you'd see in a laboratory, for example.

The clinicians that we use in our trials are clinicians on the scene. We don't hire clinicians who are specially trained, we hire the clinicians that are at a site and then they do the intervention. So that's been a trademark aspect of CAMS is to really lean into the effectiveness side of real world care. And to that end, there have been 10 open trials.

Three with control comparison groups, University Counseling Center settings, outpatient community mental health agencies in the U. S. and around the world, a bunch of inpatient trials at the Menninger Clinic, which is a different kind of hospital stay because it's lengthier. We did a series of trials [01:13:00] there, and then a recent trial with, teenagers, which is our first data based use of CAMS with teens.

So ten of those trials, which is great, and three with control groups is always better than not having a control group. But the real focus, the last 15 years has been on randomized control trials.

Tony: Can you explain the difference between an open trial and a randomized trial?

David Jobes: Open trials might be you have a group of people. They get the intervention, you look at where they started and where they end up. There's, it's just a real world setting and there's not as much rigor as might be, you might see in a randomized control trial. A randomized control trial is an experiment where basically patients are randomized to one treatment or another treatment.

In this case, CAMS versus treatment as usual. In one trial dialectical behavior therapy. And, and that's where you get into a causal relationship versus a correlational relationship. Open trials you [01:14:00] get correlational data, which means, oh, it's interesting. We see nice responses to care.

All looking to replicate the same findings. Rapid reduction in ideation, overall symptom distress, increasing hope, decreasing hopelessness, decreasing depression, lots of great data.

Tony: And in, in science, we never really have one, one test that can answer every question. So a lot of times it's about if you think of it getting an angle on from this angle, an angle from this angle, and then you begin developing an accumulation of evidence that points you.

David Jobes: Ideally.

Tony: Towards. Yeah. Yeah. so those are all very important ones to say, oh look, gosh, this happened again, this happened again. This seems to be in the right direction. This setting and that setting and these group of people in this sort of circumstance.

David Jobes: Yeah.

Tony: So that was the first, a lot of the first phases.

David Jobes: The [01:15:00] first, yeah, ten of those, and those are great, but they, we can't say that CAMS caused these outcomes. You can only do that in a randomized control trial. And these RCTs cost millions, so we've gotten funding from the Department of Defense, and from the VA, and from the National Institutes of Mental Health, different foundations for these kinds of randomized controlled trials, and now there are seven of those in the published literature.

And what's been interesting is that, CAMS and the RCTs clearly reduces ideation better than any other intervention. It's just a fact. And other inventions reduce attempt behaviors and self harm better than CAMS. CAMS does have an impact. It's just not as robust as some other interventions, and we can talk about that if you'd like.

But we have a new German trial, it was an inpatient use of CAMS, where there was a reduction in suicide attempts post discharge, which is a very high risk period. And so that was a significant finding, but a small study [01:16:00]underpowered, so you want to replicate that. So the reason that there's not a ton of studies, a ton of interventions, is because these studies are very expensive and they're very hard to do.

And of course, people die and, you know, we have very, very high bars of rigor around human subjects and institutional review boards and data safety monitoring plans and committees that can pull the plug on a clinical trial if it looks like the treatment is actually causing harm. So I'm really proud of these seven trials.

And then we had a meta analysis that came out several years ago that showed clearly across nine trials that CAMS reduces suicidal ideation, significantly compared to other interventions. It reduces overall symptom distress reliably. The single biggest effect, which I'm so happy about, is that it increases hope and decreases hopelessness, and it increases retention to care.

And then for the remaining variables, like self harm or attempt behaviors, cost effectiveness, the data were trending, [01:17:00] but it was only nine trials. But it was nine trials. And then one of the findings from that meta analysis that I was so happy about was that the studies that I was involved in did worse than the studies that were led by other people.

So that means there's no publication bias or, allegiance bias, that I'm not the only one that's finding significant effects.

Tony: Yeah. Because, and so achieving a meta analysis is a study of studies and that's the thing that many people in that sort of aspire to is having a, meta analysis where you can look at the effects that happened.

David Jobes: Across studies.

Tony: Across studies. So it must be very gratifying to...

David Jobes: Well, I don't go to conferences anymore and have people tell me that it doesn't work and that, as you can imagine, has been frustrating because I felt clinically I saw it work and we had 10 correlational trials, but really until the [01:18:00] meta analysis, that was a tipping point of sorts.

And now that the issue is does it decrease attempt behaviors? And now with this new German study, maybe it does, but an interesting thing in our field, Tony, as you probably know, is that there are interventions that really move the needle on attempt behaviors and self harm. But not necessarily ideation.

And then there are other inventions like CAMS or attachment based family therapy that move the needle on ideation, but have less clear data on attempt behavior. So there's a bifurcation of our treatments sometimes. And that's an interesting idea.

Tony: Yeah. Could you talk about, for me, that's a pretty, reducing somebody's thoughts about suicide, I guess to me, would reflect potentially that there's less pain going on.

David Jobes: Yeah.

Tony: So to me that's a kind of an important outcome all by itself. But could you talk about, I know that you, that you published a paper [01:19:00]expressing thoughts about the importance of suicide, of suicidal thinking as its own target?

David Jobes: In and of itself.

Tony: Yeah.

David Jobes: That was an editorial I wrote with Thomas Joiner, who's at Florida State University, where we're kind of like, what's up with this?

Why doesn't reducing suicidal ideation kind of count? I had a paper rejected very soundly, where the reviewer said, "Yeah, CAMS reduced suicidal ideation and symptom distress and hopelessness, but not necessarily attempts," and the paper was rejected. And it got me thinking, wait a minute, this is actually a big deal.

And Thomas in particular is like, people act like reducing ideation is not a big deal. And that's not the case.

Tony: And hopelessness.

David Jobes: And hopelessness.

Tony: And treatment retention.

David Jobes: And treatment retention. So, that's where we're trying to some extent to change the conversation. Now, if we in the current five trials have great data on attempt behaviors, I'll be talking about that too.

But I'm pretty [01:20:00] sanguine actually, satisfied with the idea that CAMS only works with this big population, the iceberg of the suicide problem, which are people with serious thoughts of suicide. 15,600,000 adults and teenagers in the U.S. Such a huge number of people who suffer.

Tony: Thanks for making that distinction.

One of the things I've noticed about even how you're talking about CAMS is that you are, you do seem like you're careful about trying not to say more than what the evidence has shown.

David Jobes: Yeah.

Tony: What areas would you want to highlight as like, what we haven't shown yet

is this or what we're still trying to gather that evidence for, even after 20 or whatever different studies that you've had? What are the things that you're still wanting to learn more about with respect to [01:21:00] CAMS and how it might help people?

David Jobes: Clearly behavior. There was a Danish trial that was independently done that was underpowered, and the comparison control was Dialectical Behavior Therapy. And DBT should have buried CAMS in this trial, to be honest, because they were a population of people with Borderline Personality Disorder features and attempt histories, and that was, like, well suited to Dialectical Behavior Therapy. But CAMS was neck and neck with DBT on self harm and attempt behaviors.

But it was underpowered, so that what was trending in favor of CAMS compared to DBT, which is the gold standard with, 44 RCTs at least, was good company to be in, but it was, ah, if they had maybe 20 or 30 more patients, we might've seen that CAMS was actually better than DBT in that trial.

Tony: So just to, so when you say something is underpowered?

David Jobes: Sample size.

Tony: We should just describe it. It means that in, in order to show,

David Jobes: an effect, [01:22:00]

Tony: yeah, in order to, if there's a real effect there but it's small or moderate, you need more people in a study to be able to detect that.

David Jobes: Correct.

Tony: And so, many times this happens when we're doing research that you start to see something and you think this could be really real,

but, but because it's not huge, we just needed more people and we don't. So that's where having additional studies and larger studies is really critical.

David Jobes: Well and after years and millions of dollars, that, that's the thing that's so crazy about this research is that it's very labor intensive.

It's very exhausting. We watch in clinical trials for fidelity and adherence. They're using CAMS as we would want them to, and that the control group is not using CAMS in this case. And that, and we get very involved in the cases and people have died and that's [01:23:00] very painful.

Tony: Yes.

David Jobes: You know, we're invested obviously. But yeah, you come close and then you kick the dirt and say, maybe next time.

But that, to your question, that is the one sort of, because the German trial was actually extremely underpowered. It was only like 88 patients, but the effect size was really robust. But it's not a lot of people, so it has to be replicated. So that, this is how clinical science goes, as you know is that you really have to have Randomized Control Trials with replication and independence, and you want to see the effect more than once, not just a one off.

Behavior, clearly, I'm very clear about what CAMS does and cautious about what it may do. But the other piece that I'm really passionate about is working more diverse populations to really see people of color. As you know, the research in our field is remarkably white and not diverse [01:24:00] and especially among young people of color.

We see in the United States, for example, some very alarming developments in terms of their suicide risk. So we're trying with that. We have a project with Sean Joe at Washington University in St. Louis, but we're having recruitment challenges. And if you know anything about American culture or history, people who are of color have cause to be wary of research.

And so we're really trying to figure out, Tony, how do we convince or persuade, in this case, teenagers and their parents to be part of the study. It's just a feasibility study to see if we can do it. And that's challenging, but we're not, we're really determined and we're going to see it through.

Yeah.

Tony: Yeah. You just mentioned teenagers. So I wanted to shift to that a bit. Are, the questions here and, and our interview has been informed by my own research, but also people on our team, people have lived experience. [01:25:00]We also asked other people are from our team who are in Australia.

and here. So one of the big questions that has come up a lot of times is, how is CAMS being used with youth? And where is the emerging evidence with respect to youth? What's the kind of cutting edge around CAMS with youth? All these kind of questions about it seems like collaborative, non coercive approach would be very applicable.

So, tell us about the current state.

David Jobes: Sure. So we had this one published trial that Molly Adrian did at Seattle Children's Hospital, open trial, where CAMS had a nice significant effect on ideation and symptom distress and other markers that we typically see. No comparison groups.

Tony: And what was the group of, of people?

David Jobes: Adolescents who were being, who were either hospitalized or in their outpatient clinic at Seattle Children's Hospital, in Washington State. [01:26:00] So that was all really encouraging and what you want to see. Certainly justified in our mind, the idea of doing randomized control trials. So to that end, there are now three trials with young people.

One called the Campus Trial, which is with college students at four different universities. And that's been ongoing now for several years. Something called the Assist Trial, which is a study with Greg Brown and the late Barbara Stanley, who, as you know, passed away earlier this year. Safety planning.

And then an ongoing trial using ketamine and CAMS at the Cleveland Clinic and Mass General Hospital. Very difficult trial to do. Lots of FDA and IRB, Federal Drug Administration and Institutional Review Board, concerns about giving adolescents ketamine, IV ketamine, intravenous.

Tony: Just to explain what ketamine is.

David Jobes: Ketamine is a very strong, powerful drug. It's also a drug of abuse. So people feel [01:27:00] uncertain, but if administered an IV dose, intravenous dose, low dose over an hour, some people have a very extraordinary response, a phenomenological shift. Feel like, "Oh, how can I kill myself?" And they're not high, they're not stoned.

They're, they just see the world differently. It doesn't happen uniformly. It's a pretty dramatic effect when it works, and the window is fairly short, depending on which study you look at. But the idea of getting this trial started was like, in that window, could we put CAMS in there? And you see what CAMS on ketamine looks like.

So they get a session of CAMS, these are inpatients before they leave the hospital and up to seven sessions post discharge via telehealth. So that's a high risk period. And the funder likes that because if you get saline, which does nothing, or ketamine, you, everybody [01:28:00] gets CAMS in the back end. So a session before discharge and then seven sessions post discharge by telehealth.

Tony: And the, the ketamine infusion happens prior to the to the treatment, to the therapy treatment?

David Jobes: The first CAMS session.

Yeah.

Tony: Yeah.

David Jobes: So up to six doses, but in a week or 10 days, you might get two doses on board. What's interesting about that is a lot of times the kids know they haven't gotten ketamine and they're like, to hell with this psychological intervention.

Tony: They've been able to detect it.

David Jobes: They feel like they know.

Tony: Or at least they, yeah.

David Jobes: Yeah. And then when they do get it, it's like oh, and you can see we've had cases where it all comes together and it's really exciting to see. We also have a study funded by PCORI, which is a Patient-centered Funding Organization, that's comparing electroconvulsive therapy with IV ketamine. Everybody gets CAMS before discharge from the inpatient unit seven sessions post [01:29:00] discharge, and that's a new trial.

It's really big. It's gonna run seven years. That's with adults. And we'll see, you know, how that goes. With the teenagers, however, and the college students, we are really up to our eyeballs in really exciting research, especially the teenagers. We're seeing stuff that we have never seen before.

It's been really fascinating. It's been really challenging. One of the big...

Tony: Talk more about that. Yeah.

David Jobes: One of the big aspects is, how do we work with parents? And, this has been sort of a, something we had to hammer out in the procedures of the study. A lot of clinicians are very parent-focused. Which is fine, but CAMS is patient-focused, and so we really want the child to perceive that the clinician is mine and not my parent's proxy.

We set up a protocol [01:30:00] where before the child gets their first CAMS session, the parents come in for 15 minutes. And we sit them down, and we say, "Folks, we're going to see your child in CAMS, which is a patient-centered intervention. We're going to focus on suicide, and our goal is to take this off the table in about 8 sessions.

And your job is to support this treatment. Now to do that, we need for you to complete this first page of what we call a Stabilization Support Plan." Lethal Means Safety. It's a page of just exhaustively going through lethal means safety and ensuring that the home environment is secure. And when we do this, it usually goes pretty well.

Even with firearm owners, there, there are thoughtful ways that we can help them make that home environment more secure. We set expectations, we answer the questions, and the message to the parents is, I've got suicide. And I'm going to be focused on your child. You've got [01:31:00] support, the home environment, and at the end of the session, I'm going to bring you back in to finish the Stabilization Support Plan.

But your job is to support this treatment to save your child's life. We're not going to have backdoor conversations. We're only going to have conversations in front of your child because I really want your son or daughter to perceive that I'm their therapist. So you'll be invited to come in at the end of interim sessions just to touch base and get an update.

But otherwise, unless it's an absolute emergency, we won't be talking outside of the earshot of your child. And for some parents, that's hard. they, that feels a little scary, but we make a convincing pitch. And Tony, with some parents, there's you can just see that they feel so grateful that they've got now a cleared roadmap of what they're supposed to do.

Tony: Yeah, I, just to jump in on that, I do feel like this is a big, [01:32:00] big opportunity because, so we often, encourage, organizations to adopt Family Support Plans that go hand in glove with safety plans. And, and, we have a member of our team who, herself has been a carer and family member of, of somebody who struggled in a lot of different ways.

But what I keep hearing as is, we want to know our role.

David Jobes: Yeah.

Tony: Now, in a way you think, you should determine your role and, you don't want to be overly paternalistic or anything, but if somebody is asking you for like, "I just want to know what to do." The most compassionate thing, one of my, one of my, early family therapy supervisors said, this is David Waters at the University of Virginia.

[01:33:00] You might know him. But he said, "The first step if you want to help people is to be helpful." And , and, so often it's sort of like, we, I think sometimes we're so concerned about not dictating that we don't always provide structure. And that's actually something that we can provide that other, there's a lot of other people in a person's life who can provide a lot.

Family members, neighbors, they're going to do most of what a person needs. But one thing that in a professional or service providing role that we can provide is tools, some structure, some frameworks. And a little bit different way of interacting. So I could really imagine that a lot of parents would feel relief at somebody [01:34:00] saying, "All right, I can't say that, I can't guarantee you this is going to be, this is going to work or be helpful, but we have an approach.

David Jobes: Yeah.

Tony: And can you go along with this approach? And I imagine that would be comforting in a way.

David Jobes: When it works, it's very comforting. And out of fear of anxiety, which we talked about earlier. Parents can over function, they can sometimes undermine the treatment, they sometimes feel blamed or threatened by the treatment, feels competitive or somehow it's their fault.

But this is, the goal of this is to do away with all that and keep the focus on saving your child's life. And we really put that down in a very direct, you know, it's about saving your child's life. That's the goal here. And so, of course, that's your goal too, right? So it's meant not to like, bop them over the head with it, but it's meant to say, this is really serious.

This is not necessarily crying wolf. [01:35:00] Do you want to talk to a parent who thought their child was crying wolf and they lost them to suicide? They have tremendous regrets. I don't want you to have those kinds of regrets. So it's very direct. It's intense. It's CAMS. And usually the parents are okay with that.

And the child comes in and, oh, are they the expert on everything, including themselves? Yeah. Do they love CAMS? They love CAMS. Because CAMS is about, you know, you're the expert, you tell me what you're going through and why you want to kill yourself and, you know, and I'll listen and validate you and track you and propose an alternative model to get your needs met and Stabilization Plan and then the drivers.

Now, if the mother haranguing them about cleaning their room is why they have to kill themselves, we'll bring mom in, but we don't necessarily presume that the parents are the problem. And in CAMS, that's always really hard for a lot of clinicians because they [01:36:00] know it's the trauma, or it must be the substance abuse, but not necessarily from the patient's perspective.

And so that's how that first session goes, the parents come in at the back end, we share the child stabilization plan with them so they know, we talk about the two problem drivers, so they know about those too, and that's what we're going to be treating in the course of care. And we complete the second page of the Stabilization Support Plan, which is very specific with the child there.

How can your parents support you differently and better? What don't they say? What do they say? Who can they bring into your life? Who do they keep at bay? What can they do to be better parents to support this treatment that's designed to save your life? And that's the first session. Now that gets budgeted at an hour and a half, which is a lot of time, as you know. But it sets a trajectory where then, in the interim care, we just start with the core assessment, we craft the stabilization plan, treat drivers, treatment plan [01:37:00] update, parents come in for the last 10 minutes, we update them. And so we've got, so that trial is about a year in, we've got about two more years of data collection.

It's really hard research to do, but encouraging, and we see this model and the Stabilization Support Plan as being a big, a big player in the parents having a role, as you were saying, that of how they can be supportive of the treatment.

Tony: What have you noticed so far, the people who are delivering the care, what are they noticing about the kinds of drivers that youth are identifying?

David Jobes: A couple things. A lot of it is peer based, which you guessed, bullying, online based stuff. Kids, get hospitalized and they're out of school and then going back to school gets really scary. One thing we saw that came up when Barbara was still alive was, that safety planning, as you know, is indexed to an event, typically an attempt or acute crisis.[01:38:00]

And when we were first starting the trial, Barbara and Greg and Kelly Green, who's also on the team, were saying, "We're finding kids here who don't have an index crisis event to do safety planning with." And as we started to look at this, the crisis was that the parents found out that their child had suicidal thoughts.

And that was the crisis. The child had thoughts for several months. So we were like, wow, didn't know that was going to happen. So we worked with that to modify the inclusion criteria. So the safety planning would be effective and successful. But things like that are fascinating where we thought the crisis that got the child hospitalized was that they had an acute episode.

No, they've been suicidal for six months. The parents found out that they were suicidal and then raced to put them in the hospital or put them in the emergency department.

Tony: Wow. So it sounds like a lot of work is happening with youth and learning about [01:39:00] new ways to both sort of structure and support parents and, and it's amazing how many different studies you could have going on at the same time.

I imagine that must be through collaborations and, and teams. Can you talk about the, what different collaborations and teamwork has meant to you across this work?

David Jobes: It's meant everything, because I'm not a great treatment researcher. I, I was a PI of one big 3.4 million study, and learned I'm not a great Principal Investigator.

It doesn't play to my strengths. But I've done three clinical trials with Kate Comtois, who's at the University of Washington in Seattle, who's a protege of Marsha Linehan's and Marsha's a big influence in my career. Kate's been a great PI. She's amazing. And then I've worked with Pete Gutierrez and Lisa Brenner.

And then we've worked with [01:40:00] the guy Colin Depp at the San Diego VA, who's a brilliant researcher. Molly Adrian, Jeff Bridge at Nationwide Hospital in Columbus. I'm in this enviable position, having worked at this for 40 years, of people approaching me saying, can we use CAMS in a NIMH grant and RCT and yeah, as long as I don't have to be the PI, cause I'm not good at that.

I'm good at many things, but I just, that, as you know, Tony, it's, it requires such a skill set around budgeting and a lot of stuff to be a Principal Investigator of a big multi-site million dollar plus grant. So, I was a member of the ASHI group, which is this group in Switzerland of colleagues that you are near and dear to, that developed this intervention, ASIP, the Attempted Suicide Short Intervention Program, which you're doing a trial in.

So I, I feel I've been the beneficiary of an incredible group of collaborators. When I wrote [01:41:00] my, my, my Department of Defense grant, David Rudd, who did a big RCT of something called Brief Cognitive Behavioral Therapy, BCBT, which is a cognitive therapy intervention for suicide. A cousin of cognitive therapy for suicide prevention with Aaron Beck and Greg Brown did.

David just gave me his budget. He just gave me his multi million dollar budget. And I was in Denmark and I wrote the grant proposal mostly in a hotel room. And my colleague, my friend David, just gave me this budget. And I'm terrible at budgeting, both personally and professionally. So it was just such a gift.

And what's interesting in the suicide prevention field, which I'm sure you've experienced, is that it's not for everybody. It's a buzzkill for a lot of people. When I got our DOD grant, we would go to Fort Detrick in these interim reports, and the colonel one time came up to me and said, "You suicide people are really interesting."

Like you hang out, and you give each other pointers and ideas, and you're so collaborative and so supportive of each other and tips and [01:42:00] pointers. He said, "When we get the TBI, Traumatic Brain Injury people or the PTSD people. They're like in these little silos and they see each other as competitors and they don't hang out."

And I thought, huh, yeah, that's the suicide prevention field. Not for everybody, but for the people that are in it, we're in it for the cause and we tend to like each other and we work together and try to collaborate as much as we can.

Tony: Yeah, it's powerful. What, one of my most important mentors is named Peter Wyman at the University of Rochester.

And he said something that really resonated with me. He said, "I can't do anything by myself anymore. I can't do anything good by myself," or something like that. And I think, especially when you're tackling difficult problems, having people who share like that and then sharing with other people is, it does seem like pretty, pretty important and beautiful.

David Jobes: Our campus trial, we have 24 people [01:43:00] every Thursday from 2 to 4 on Zoom call. It's, it is a village. It is a, of people who are doing assessments, and people do stats, and people that do the IRBs, the Instructional Review Board, and the Data Safety Monitoring Board, and all the NIMH stuff, and then the PI, the Principal Investigators, and all the, that does, then there's dozens of clinicians.

It's, quite the enterprise, as you know.

Tony: Yeah. I, yeah, sometimes I wonder, when we're, you know, sitting around fretting about, are the, we go through a lot of, for example, to make sure that the people doing the assessments are blinded, meaning they don't know which,

David Jobes: treatment,

Tony: intervention the person got so that they don't put a finger on the scales.

And I just I sometimes I've been, when we're going through these measures, I wonder I wonder how much people, realize that it goes on behind the scenes. And, but sometimes I feel sad because it feels [01:44:00] like, I wish that for the field, especially for groups that are disproportionately affected by suicide, I wish we had more to show.

David Jobes: I know.

But it's a young science, Tony, as you know. It's a young science. The folks in LA put this on the map in the early 1960s, and I would say, and I bet you agree, in the last five to ten years, there's been a tipping point of much more rigor. Much better quality research, and we've got a ways to go, but we, I think I have a lot more to show for it than we did maybe even 10, 15 years ago.

Tony: Yeah, no, I appreciate that. That is an encouragement to hear. And I think, what you said before about part of your commitment is also to make sure that we both adapt, but also test, how different treatments work with diverse [01:45:00] populations.

David Jobes: Well not, and not just assume, and this is a big one, that because it's well intended and we're trying to do good, that necessarily works and doesn't cause harm.

So that's a big one. I'm on the suicide, I present...

Tony: And for who? And...

David Jobes: Yeah, and for who and all that kind of thing? And so I'm, there's an evidence based practice listing now that the Suicide Prevention Resource Center is putting together and I'm on the, I'm on the steering committee or something. I can't remember, but that, but it's, a really needed thing.

And my argument is okay, these, are all, I'm sure well intended. Do we know that they don't cause harm? And, so that's, people never think that. I can tell you exactly how many people I know have died in CAMS trials, and how many, at this point, thousands of people who've been in trials who've done well. And overwhelmingly what's clear is that we're not going to save every single life, but we sure are going to try, and no [01:46:00] treatment's 100 percent foolproof.

But one of the things that we've seen on the unseemly side of fear of liability was a case that occurred heartbreakingly, where a college student took her life, clinician did CAMS, and a year or so later, and I consulted on the case and gave feedback to the provider. And she did a great job, in my view.

She did a really good job, and it was a tough case, person with multiple attempt history. And the parents came across the patient's documents, the SSFs, a year later, didn't even know that she was being seen by a clinical psychologist at this counseling center on the West Coast. And the mother called the clinician and said, "What is this?"

And the clinician's heart dropped, said, "Oh boy, here we go. Next call [01:47:00] is from the lawyers." They talked for three hours. At the end of the conversation, the mother said, "It's all my fault." He said, "Well, actually on reasons for living, you were listed as one of our reasons for living. And I never heard her say a negative thing about you or your husband."

They get the husband on the call. And at the end, the parents, the mother said, and the dad joined in, and, "How are you doing?" And what can we do for you? Because of course you lost your patient, our daughter, and is there anything we can do for you?"

Tony: That's really encouraging. And I, think actually we're, as, we're doing quite a bit of work on, trying to create cultures that are, that address the needs of people impacted.

Our colleague who I know that you have met, Dr. Kathy Turner from Queensland, Australia, [01:48:00] has just taught me so much about this and has published some really interesting papers about the, the need, really the, ethical requirement that if we're going to try to call people to bold goals around suicide prevention, that we be there for people, family members, people in the community,

clinicians involved. Whoever are the impacted parties and understanding, who's been hurt, what do they need? And holding ourselves accountable to learning.

David Jobes: Yeah.

Tony: But in a forward looking approach where it involves healing and improving and growing. And, where those kinds of conversations can happen and, yeah, it's really, I think it's a really important and I know I'm sure, many of us, and I'm sure people who [01:49:00] are listening in on our conversation have, have experienced loss.

And, I know many examples where, there weren't open conversations asking about who's been hurt and what do they need, and coming to terms. And this is what I understood, and this is what you understood. So I'm, it's very heartening to hear that conversation took place,

and, I do think that we're ready in the field to have, have a different approach when those things that we're working so hard to, to support people so that doesn't happen. But when it does, that, that we can have something that leaves people.

David Jobes: Yeah. A defense attorney is going to say, circle the wagons, don't talk to the family, keep your head low and let's just try to get out of this.

Tony: Yeah.

David Jobes: [01:50:00] When Marsha Linehan, who had lost patients in DBT trials, had a whole protocol. They went to the funeral. They sent flowers. She met with a family if they wanted to meet. She took responsibility. And I'm sure the lawyers went crazy, but it was the right thing to do. Eric Harris, who's at, for the National, the Trust of Trust Insurance for Psychologists.

He and I did a webinar, and I do like risk management and ethics, and I teach ethics in my program. So I'm fascinated about this whole interface. And he said, he said, "When these crises occur, the number one thing is to be a decent human being."

Tony: Yeah. And I think attorneys are getting that too, now.

Maybe not all of them, but I think a lot do.

David Jobes: I think.

Tony: Yeah. And actually, it's really interesting in this project we're working on around what Kathy and other colleagues have called Restorative Just and Learning Culture, a mouthful around the concept, but, we, [01:51:00] had the opportunity to interview the Coroner of the State of Queensland and, we're, because many times the objection to a very open collaborative process is that, how are we going to, if this, if we don't have like, an objective, find out what happened, what went wrong, root cause analysis, we're going to get raked over the coals when this goes to the coroner.

And that's often in, in that setting, that's the threat. We a lot of times think about like malpractice attorneys and worry about the coroner. And this very wise and articulate coroner just talked about how important these kinds of open processes are.

They're very supportive of a, of a Restorative Just and Learning approach. Very supportive of, of involving [01:52:00] family members, affected people, in examining what happened and giving perspectives and identifying. And one of the interesting papers, most recent ones, that Kathy and her excellent colleagues published.

So the, actually the recommendations that come out of that are stronger. And my contention would be they also probably are more likely to happen because you have buy in from the people who are part of it. And, yeah, I know that, I think it's still, we're still a long way. I think that the typical processes and even the things that you have to report to the state are really around what policy wasn't followed is the main, is often the primary question as opposed to who's been hurt

and what do they need? A very different set of questions and perspective. You'll get at where do things need to change? But, yeah, so thanks for [01:53:00]sharing that story. As we're talking about these things, and I guess we're, we've been talking a little bit about too, but the field of suicide prevention tends to be collaborative and tends to draw people, I think, who are, actually optimists.

David Jobes: Yeah.

Tony: Even though we deal with such a painful, you know, painful problem. I'm wondering what your thought is about, why that is? Why do you think that, that suicide prevention seems to draw that kind of collegiality?

David Jobes: I think it's 'cause it's so hard. If you've lost someone to suicide, it's just such a wretched way to lose someone near and dear.

There's so many questions that'll never be answered. I think it's not for everybody. I know you get this, I get this all the time, "Oh, how could you be in such a morbid field?" And I was like, "Oh, saving lives and, and pulling people back from the brink? That, that to me is incredibly exciting."[01:54:00]

So there is that kind of cynicism or kind of wariness of the topic. But I feel like the joie de vivre in my lab, the way the students are, that we're in this really exciting cause. And it isn't even for me, Tony, as I grow into this field after 40 years, about preventing every suicide, it's become more about giving people second, third, and fourth chances and focusing on suffering.

And that goes to the 15.6 million who have serious thoughts of suicide, according to our SAMHSA, our government data. So many people who suffer. And just because they haven't made an attempt doesn't mean that they don't deserve care. In the National Health Service in the UK, you don't get evidence based DBT until you've made an attempt.

Short of that, you get supportive counseling. Operantly, [01:55:00] there's a system that's basically telling people, you gotta ramp it up for us to give you a treatment that actually works. That just makes no sense to me. I think people are drawn to this because they, it affects them personally. I'm passionate about living.

So that's my thing is that I really believe in a life worth living and really believe in the psychology of life. And I'm a student of that. And then I've just worked with hundreds, maybe thousands of people, where this doesn't have to be the way you get your needs met. And you can find a way through an incredibly dark moment and see the other side of that and look back on that and say, "Oh my gosh, I almost ended my life."

And I've had people look me in the eye and say, "You saved my life." And if you've ever had that experience as a clinician, it's about the most profound thing a person can say to another human being. And I would never like take sole credit, but I'd say, "Yeah, [01:56:00] we found a way, we, not me, we found a way to make your life possible."

Tony: You mentioned people saying, boy, this is a really morbid thing. When you do introduce, like when you're meeting somebody at a, in the neighborhood or, and they ask you what you, how do you say it?

David Jobes: I don't tell them.

Tony: No?

David Jobes: I start, I, you know,

Tony: What do you say?

David Jobes: I'll say, "Oh, I'm in education."

And then they'll say, "What do you do?" "Oh, I'm a professor." "In?" "I'm in arts and sciences."I have a whole gauntlet.

Tony: Yeah. You gotta get through a few gates to find out. Yeah.

David Jobes: If they're very persistent, I might get to the fact that I do suicide research, but I, and then I can clear a room. That's where my, sort of, my joke is that, because most clinicians have this experience like, oh, are you analyzing me?

You know that sort of wariness but suicide is like really yeah, you know. [01:57:00]

Tony: How much do people, you know, outside of professional circles like in your family, neighbors, people, you know, your parents of your friends, your kids friends. How much do they know about your work?

David Jobes: If they're close, they know a lot about it because we live it.

And my whole family, my wife has been a Lifeline volunteer and she's the founder of our training company. And she's a lawyer, but she's really good at this stuff. She's a loss survivor herself. She lost her mother when she was a teenager. And both my sons have worked in the field as well. My one son worked in the Lifeline, worked on the text line and my other son worked for American Foundation for Suicide Prevention and Policy.

So it's kind of the family business. And we all feel passionately about it. And then their friends know. And it's, I think for people that get beyond the first blush of, "Oh, what a morbid topic," that they find it admirable and [01:58:00]serve up a really interesting, compelling, which I think it is, cause.

Tony: So looking into the future, I'm wondering what kinds of things you were hoping for in, in mental health and in suicide prevention? I noted that in a few different places where we have interacted, I've heard you mention the idea of a, like a Peace Corps for mental health or a, a mental health service corps.

Could you talk about that idea?

David Jobes: Yeah, I just think there'll never be enough clinicians for 15,600,000 adults and teens with serious thoughts of suicide. There'll just never be enough clinicians. So if we really want to move the needle, we need a massive workforce. So it's been a moonshot idea, but the idea would be like a, it'd have to be federal.

It [01:59:00] had to be broad based. We know with our new 988 Lifeline number that we have capacity issues. We had capacity issues in the crisis line that we have here in the United States before it was a 988.

Tony: So we recently got this, for those who might not know about in the U.S., we recently got a three digit number that you can call and that's for mental health and suicide crisis.

David Jobes: Right. And so we had a 40 percent bump in calls as soon as it was made easier. And the federal government's rolling this out very slowly because the American populace needs to know the difference between 911, which is our emergency response.

Tony: Call the police.

David Jobes: Call the police response, versus 988 which is suicide and crisis.

And that's a big thing for the public to appreciate. So I'm obsessed with the crisis space and stabilization. And that stabilization in and of itself should be a goal. So there's something that we call the HOPE Institute in Perrysburg, Ohio, that where all they do is [02:00:00] CAMS and dialectical behavior therapy.

And all they do is see acutely suicidal people and stabilize them. Kids in 5.2 weeks and adults in 6. That's all they do. Next day appointments, up to four sessions a week, we are getting people more stable. Because as you know, their next outpatient appointment may be six months, weeks or months.

And so I'm trying to put on the roadmap in the policy work that I do, the importance of stabilization as a goal in and of itself. Because I, I'm not a fan, as you've heard. I'm not a fan of emergency department visits where there's very little that can be done and oftentimes it can be a very negative experience, somebody being boarded.

We had a child in Maryland where I'm from that was boarded 60 plus days waiting for an inpatient bed. And then after two weeks on the inpatient unit, died of a seizure. And the parents were like,

Tony: What just happened?

David Jobes: what just happened? That is not therapeutic. So we [02:01:00]have an intervention. That's a tablet based intervention called Jasper Health that we can use in the ED because, and we budget four to six hours of people to engage because they're waiting 8, 10, 12 hours over night to see the doctor.

We can engage them in a thoughtful, it's informed by CAMS and, we've got data that it's effective and so forth. I'm just a big fan of respite care, of retreat centers, of technologies, of social workers being the first touch in a crisis with police is backup versus the police being the first touch in the, and organically, that's popping up all over the country.

So I'm, I'm a part of a legislative advocacy with the American Foundation for Suicide Prevention, a public policy chair. We're very focused on creating legislation just for stabilization, so we can reduce emergency department visits and inpatient care that's not necessary and get people stabilized.

Tony: That's really exciting.

David Jobes: It [02:02:00] is.

Tony: Yeah. So it sounds like a lot of your energy is, or some of your energy at least is towards advocating for the, for a future where there are more options.

David Jobes: More options.

Tony: Both in terms of who might be there to support, where people might get support, what that support looks like, and all of it may be being more timely and humane.

David Jobes: Mental Health Service Corps could take students out of college, give them some loan forgiveness, take people lived experience, train them. You don't have to have a Ph.D. or an M.D. or a master's degree to do safety planning, or lethal means discussions, or caring contact follow ups, or to person the National Lifeline.

So I just feel if we were able to, and it's a big, everything's political, as you know, and it's a very tough sell, and it'd be very expensive, but if we built this massive workforce of paraprofessionals, then we could, I believe, move the [02:03:00] needle.

Tony: Kind of like, things have happened with teaching when we faced a crisis around having teachers in difficult areas that people don't want to teach or, in places around the world.

So it's a really interesting idea. Has that gotten any interest or traction yet? Or is it at the kind of the

David Jobes: People find it intriguing.

Tony: inspiration phase?

David Jobes: People find it intriguing. In 2016, we were talking to people that knew people for the losing presidential candidate, as there was some interest then. There's interest now.

It's a tough sell though. I will say this in the policy side, living in DC, is that this is a remarkably nonpartisan issue. That 988 got passed. That bill being passed had something less than like a 3 percent chance of passing. There are hundreds of bills that get submitted to Congress and very few actually pass, especially in our incredibly polarized political climate [02:04:00] and that the president actually agrees to sign off on.

So in the previous administration, that bill passed. It was like incredible. It's a watershed in our nation's history to have a, to have simplified reaching out for help. But there are controversies like, active rescue is the idea that somebody will check up on you and a lot of those people are policed with guns, and if you're a person of color, that's

probably not a welcome sight. In the UK, the Samaritans don't trace calls and do active rescue. So there, there are lots of controversies around this, but the good news is this is a nonpartisan issue. Everybody knows people who are suicidal. No one's immune, as you know. And so there is a lot of goodwill and a lot of funding headed towards mental health like never before.

The NIMH has completely moved to a much more suicide-focused agenda. The new direct, the newish director, has made this a high priority and it's transformed. [02:05:00] I know people that were working in depression who become suicide researchers because that's where the money's going.

Tony: Yeah, it's so interesting because, and this is, I think also it's, I think it's a good lesson to follow what, where you think you can make a contribution.

When I was just, you might know that it was after the death of somebody that I knew that I became drawn into suicide prevention and from that into research. So I wasn't, I was not a researcher, not as interested in it earlier in my career and then became really interested when I felt like this is a way I could help with this problem.

But, a number of people discouraged me from going into that because they said, NIMH, National Institute of Mental Health, the primary funder for scientific research in our country, they're really moving away from suicide. You really ought to, there's much more interest in

David Jobes: Anxiety.

Tony: Whatever it is.

David Jobes: Depression.

Tony: And, and actually there was, I, what the advice I [02:06:00] listened to was actually some that my father gave me. My father died when I was relatively young and a lot of the advice he gave was probably not that good. And we had some conflictual things in our relationship, but one really good piece of advice that helped was, that there's always room for good work.

And, so I decided that to stick with this and then of course it comes around. And I think this is, a lot of times people who are just entering this field or really any field are wondering which, how should I do? What, which direction should I go?

Should I be following this? And, and right now I think there's a lot of question about should I do, be doing anything that's not AI? Artificial intelligence, and, I think we probably need to do a lot with [02:07:00] artificial intelligence and we will be working alongside artificial intelligence agents for sure.

Don't chase trends. If, follow where, where you think you can contribute right now. And not out of fear like something's not gonna be there for you if you follow what you're interested in and where you think you can contribute. So there's been a kind of a lesson there. I wonder, like for you, when you're, when you hear people either entering this field or kind of who are, finding their way into, into a field, what are some things that you think are important?

Maybe what you usually, what you share with people?

David Jobes: That's my senior seminar, I mean, the Psychology of Life class is about mentoring. It's about staying the course with something you actually care about. It's about persistence. I wrote grants for 10 years before I was funded. People think I'm

so successful, [02:08:00] but for 10 years I just got rejected. It's about, to me, following your heart and it sounds corny, it really was something I, when I was working inpatient, there were all these things that were being done that made no sense to me, but like we had patients sign no harm contracts promising they wouldn't kill themselves.

And I, I did it, but it's like, how is that effective? So there are a lot of things like that in my own experience base that kind of compelled me towards, because I didn't plan to be a researcher, I was really going to be a clinician private practice. It was just something I discovered and then all of a sudden I was like really interested in it, and then it just became my passion.

And I was, just stayed in my lane. So I just, I, like what you were saying, I just stayed in my lane and I didn't go here. I didn't go there. I got to know Aaron Beck, the founder of Cognitive Therapy, who was very supportive of my work. I got to know Marsha Linehan, who's amazing. I've gotten to know the founding fathers of our field.[02:09:00]

And I just stayed in my lane, stayed in my lane, kept on doing my thing, and just doing the next steps. And now 40 years later, I look back on that and say, wow, what a, what an incredible journey it's been to make the contributions I've made and to still look forward to making others.

But, that is my senior seminar is to say, we're all on a journey. You can live that in an examined way and live intentionally or not, but in that class they have to think about it. And for some it's like really exciting and it really stirs them up and for others it's, "Oh, I thought I had it all figured out," and it's upsetting. But I'd rather have them think about it now

at 21 or 22 than at 65 and saying, "Oh gosh, I kind of wish I had done that." And to me that, that's like a nightmare that I'd love my students to not have to go through.

Tony: So either for that class or in, in other settings, are there books that you, [02:10:00] recommend? What kind of, what are the books that you most often recommend to people, either in the Psychology of Life class?

David Jobes: We cycle through a lot of books, but I'll tell you that, The Alchemist is one that I like. It's like a world's bestseller. It's about a person's journey. Somebody who was hospitalized by his parents, multiple times as a teenager. Man's Search for Meaning, which is Viktor Frankl's classic about surviving Auschwitz.

I'm a big fan of Mindsets by Carol Dweck. I like, Angela Duthwerk's Grit. I'm cycling those books out now for another book, called The Midnight Library. Very interesting book.

Tony: I haven't heard of that book.

David Jobes: Yeah, it's a very interesting book written by this guy who's a very near suicide attempt or a completer.

And, without giving away the story, it's about possible lives. I'm keen on, one [02:11:00] of our students actually wrote a book called the Power of Meaning. So books like that, I just, I'm really, I'm, I've always loved existential philosophy. I was a philosophy major until my philosophy professor said, get out of it.

It's a dying profession. Switched over to psychology, which is probably a good move, but I've remained interested in philosophy. And so there's a lot of books along these lines that I find just riveting. And so we kind of cycle through and the students love them. They hate them. They get really activated typically.

But they're talking and they're thinking and they're, it's a, their life is a little bit more examined by virtue of what we do there.

Tony: It's been fascinating to hear about your work and about these different people who influenced you. And it's been a special privilege for me because you influenced me a lot.

And I think, many of the things that you talked about today, the values that you've infused into CAMS and the heart [02:12:00] behind being collaborative, honest, transparent, focused on person reducing that hierarchy, coming alongside. All those things when I was really making that transition and entering the field that really shaped my lenses for all the other work that's come after that.

I also appreciate your involvement in the research that we're doing at the University of Rochester, so it's been really a privilege to hear about some of those things that shaped you, that are still shaping CAMS and other parts of your work, so I really appreciate you talking with me.

David Jobes: I feel like, Tony, we need all of it.

When I talk to students, a lot of times I talk about, they're like, everything cool has been done. And I'm like, oh, gosh, this is the tip of the iceberg. Working with SafeSide, for example, or working with different systems of care. I [02:13:00] really feel like care transition is a huge thing.

And I know you guys are about that. I really feel like there's not one treatment, that one size doesn't fit all. You don't have a hammer, all the world's a nail. You have different tools for different needs and requirements. So I've never been more hopeful about the field than I am right this second. And it's working with people like you and other dear friends, who are so passionate about this topic.

And I, I really feel like for young people now, this can become a career. Like it, it can. Like I was warned like you were. There's no future in this. You'll never get tenure. You'll never become a full professor. We proved them wrong by staying the course and believing what we believed in, and listening to our patients.

Tony: Well, thank you. Appreciate the time and we'll keep working on it together.

David Jobes: Thanks, Tony. You too. Thank you.

Tony: One [02:14:00] of the exciting things for me in this conversation and learning, more detail about CAMS. And some of this I've heard before in other settings and just wanting to share with people is the opportunity that we have to collaborate now between our work at SafeSide and your work through CAMS Care.

Maybe, would you share about, what CAMS Care does and your mission with that? And maybe you can talk a little bit about how we're...

David Jobes: Sure. CAMS Care is a training company I founded with my wife, Colleen, and our dear close friend, Andrew, who's our business person.. And, it's a training company and we do consultation and it's, began to organically and it's evolved now into, a business.

Marsha Linehan pulled me aside early on in my research and said, if you ever hope this to go any place, [02:15:00] you're going to have to scale it up with a business. And as you know this, in academia it's like, oh, business, money. But she's right, and she founded Behavioral Technology as a way to scale up Dialectical Behavior Therapy and DBT is world famous because there was a business supporting its expansion and scaling and its training and use.

And so, I took that to heart and my lane is to do the research and then CAMS Care does the training and dissemination, and we're trying to create training hubs, around the world, literally, and across the nation. And so, that business is not just training clinicians in CAMS, we also do free webinars.

My wife Colleen develops a, an email that goes out every month about grants and about recent findings and so forth, and we're really trying to contribute to the greater good. It's not just about money. The money that we end up making goes right back into the business to further impact the cause.

So that's been really gratifying. And then [02:16:00] part of that gratification is then collaborating and linking with SafeSide and other organizations that, because CAMS is a, is basically a treatment but it can't just live in isolation. It's got to fit into a system of care. And I've always done systems work. I was part of Zero Suicide since its inception, and worked with our colleague in Australia, very involved in the dissemination of Zero Suicide as a policy initiative.

And I've always done process improvement projects, which is a fancy way of saying, how do we lift all boats so that the care for patients and their families is improved? And I've loved that work. And so, that's why I'm just so excited about the prospect of working together and what we can do in this additive way because we need all of it to move the needle.

And that's, that to me is like the whole point.

Tony: Yeah. Yeah. It's, I think, I think there's a really good match here because [02:17:00] we have a Framework that kind of covers the whole of how do we improve overall, really in a way like Zero Suicide, taking it to its next step.

What are the best practices? How can we get everybody on the same page, like literally, one page that shows the whole thing. And, and one part of that in our response is, providing evidence based treatments and what we call Mini Interventions, which are things that we can do or say that are based on those treatments, even for people who aren't in roles where they're treatment providers. And so, yeah, so, so for me, it's really, I'm excited about being able to not just point to the need to provide evidence based treatments, but for SafeSide to actually be providing that training through our partnership with you at CAMS Care. [02:18:00] And, yeah, I really know what you mean about, and it's interesting to hear it, but what, Marsha Linehan said that the genesis for me in, in wanting to found a for purpose organization, I didn't know how it was going to be. What legal entity it would be, but wanting to form some, some organization that could take work that we were developing and testing inside of the university and maybe other people's work and have a greater impact.

My mentor and I, Peter Wyman, who I mentioned before were at lunch with a really well known prevention scientist and who had incredible interventions. These were outside of suicide prevention, but had amazing trials, very high impact papers. And in the course of this lunch, he said, "Hey, [02:19:00] guess how many people are using our intervention?"

And I thought, I was like, I was pretty junior and I thought, oh my gosh, he's going to say a million or something big like that. And he was like, zero, absolutely zero. Outside of research trials, this intervention is not being used. And he was about to retire and move into an emeritus, which is like a retired professor role.

And, and that, I was like, woah, and that was one of several things that happened almost at the same time that, that made me think, I want to figure out how can we take things that have been tested and make them applicable, adoptable. How can we develop models of education [02:20:00] that

David Jobes: support,

Tony: support the kind of work and are consistent with it. Where we can encourage people to be interacting and, and yeah, so I think we share that desire to there's so much need out there.

How can we get things out there?

David Jobes: Yeah. And let me say something about that, Tony, because we have certainly had the experience of a medical director or chief of a clinic saying, we're all doing CAMS, and there's no support. And the clinicians act out. They won't learn it. They won't do it.

They won't do it as adherently. They don't, on consultation calls, they don't have cases to present. They actively fight it. They actively fight it. And that happens. And so what I'm especially excited about are ways to prime the pump [02:21:00] for a system of care to welcome intervention because what we know from the research is that clinicians like it and they feel more confident.

And they feel more competent. We have an integrated training model that we've proven is effective. Each component, including role playing, which clinicians hate, and consultation calls, which carry the day of adherence and dissemination. But if the system isn't there to support it, it's an investment that goes no place and doesn't help anybody.

Tony: Yeah. We talk about there being, like three areas of work for a, for a systems approach to suicide prevention. One of them is a culture of safety and prevention and that's where leaders come in, that's where also having real and meaningful participation from people with lived experience comes in.

People who are in leadership, meaningful roles, not just adjunct advisors, but meaningful roles that, and that does that kind of, [02:22:00] tilling of the soil, maybe, like you were talking about. So a culture of safety and prevention. Best practices, policies, and pathways. So we want that the things that people are doing to, where there is evidence, adhere to that evidence, where there's not, at least be in tune with sort of the best that we know right now.

But that's going to be supported by the third, which is a really robust approach to workforce education. And not just thinking about single point training, but, but having a whole program that keeps people engaged with suicide prevention education over time. That suicide prevention education isn't something that you did,

it's something that you just do. It's an ongoing thing. And I think, what I, I hope we can bring to [02:23:00] this partnership with CAMS-Care is, if we can work with those kinds of leaders who want to develop a culture for prevention, who want to put in place best practices, policies, and pathways, and who are supportive of a robust approach to workforce education, then you do have that groundswell of people who want to, who want to take on an evidence based

treatment framework. Who are going to feel like, yes, I want to be really good and compassionate and collaborative about safety planning, but I also want to address the drivers. And if you create those values in a system, then yeah, I think you can hopefully avoid any of that. These are very well known challenges with adopting evidence based treatments of all kind.

David Jobes: Yeah. What you're describing is baking it into the system where [02:24:00] it's just what we do. And where we've seen the most success is where a version of that happens. And there's, there from a bottom up perspective. The clinicians and the culture that's created around the intervention, sustain it. So it's not just a one off, and that when there's staff turnover, people are eager to get up to speed so they can continue within the culture that's been created.

Tony: What are some things that, that leaders in, in a system adopting CAMS as part of its, of its kind of best practices, and what are some things like maybe some things that people run up against or where things can get challenging? What are things that people should know and plan for ahead of time to help that go well?

David Jobes: That there's going to be pushback, that clinicians are going to almost automatically push back on something new. And the evidence should [02:25:00] matter, or decreasing liability should matter, or just wanting to be better at your job should matter. But that there's, there are a lot of people that are very reluctant to change.

Again, going back to fear. But if you can engage them, and the other thing I would say is not voluntolding, if that's a, if you've heard that expression yet, that clinicians are voluntold to do this intervention. That's the kiss of death. But if they can, if you can create like a organic level of interest and maybe even an internal community. You might do something like this in SafeSide, where the people who are being trained and who are to do the changing feel like they have some involvement with that process. Right?

That can carry the day and not saying, we're going to do this. We have had examples where in large systems of military based care, the colonel says we're all going to do this and then [02:26:00] people act out. Best intended effort, but the, but what was missing was a way for everybody to feel like this wasn't being foisted on them.

And in hindsight, what we talked about was a counterinsurgency model. Where we go where we want, we're wanted, have success, and then propagate out from there. So I'm just fascinated with what you guys do in SafeSide because to me, it is the soil within which life saving work can grow. But if it's not properly prepared, then you drop this training in and people, just by human nature, they like what they know.

It's one of the reasons, Tony, we're doing so much work with young people. So in the ---VA in San Diego, for example, where we've done a randomized control trial, the trial's going to click data through March of next year. But we're setting up a stabilization, a suicide stabilization clinic, that's gonna be

mostly CAMS and the focus is on stabilization, [02:27:00] training students. Because the students in the trial were a hundred percent of the clinicians. They, they were all students in training. They weren't licensed professionals and they were awesome. And cost effectness. So we're setting up a clinic in this, in this one VA center in San Diego

where that's, that's the model. And we see across a number of our RCTs that young people in training under supervision are on fire for this because they really feel like they're doing something effective and that can make a difference. But the systems level of all aspects are huge. And that's where SafeSide, I think, comes in.

Tony: Yeah, well, it may be that one of the ways is to, offer people an opportunity rather than, you know, a requirement. And, you know, my, my experience is that, in many places, people are very hungry for education, [02:28:00] and, and, learning. And my thought about burnout, yeah, sometimes burnout is because of, like, the work is difficult and, and the, the, the problems are challenging and the, and in, or the, or the workload is a lot.

But I really think at the heart of, of burnout is when people feel like they're not growing. That there's not, I'm doing the same, it's, it's one thing to have a lot of work. Everybody has a lot of work, but if I'm, if I have a lot of work and I'm, and I feel like I'm just

David Jobes: treading water,

Tony: walking the pace of, yeah, or treading water.

And I think that's where we, where people start to feel burnt out and, and one of the, you know, whereas I think if we can continue to provide people opportunities, and one of the things that is a, like a promise that, that we're trying to make to organizations, that SafeSide is trying to make to organizations, is if there are [02:29:00] people, who work for you, if they want to develop suicide prevention expertise and want to reach, you know, really being, you know, none of us have this solved and in a way you can almost never, I always shudder a little bit when people say a suicide prevention expert because I don't think we, everybody has this, you know,

David Jobes: all the answers

Tony: Sure. Done, yeah, we got the answers, but if somebody in your system wants to grow and reach, you know, being at the, you know, top 1 percent of all people who in terms of best practice and evidence based practice, we want to provide that person the pathway. Not every single person is going to be that, but you don't need based on network theory and a lot of evidence from dissemination and implementation research. You don't need every single person to be a thought leader by definition. We don't, we, you need key people who are kind of key opinion [02:30:00] leaders within their networks to take those on. And then you can begin, kind of shifting an environment and a network and, and so we're, we're really pleased that part of that pathway that we'll be able to, that we're now able to provide people through working with, with CAMS-Care, is that, is that ability to say, well, I'm, I'm gonna learn a new treatment.

Yeah, that is effective.

David Jobes: Well, and on our side, our credo is best possible care, whether it's Dialectical Behavior Therapy, or Cognitive Therapy for Suicide Prevention, or Attachment Based Family Therapy, or BCBT, or ASSIP. We don't really care, or CAMS. We just feel like people who suffer and struggle in this way should expect and deserve the best possible care.

So perhaps between our collaboration, we can look forward to trying to provide that for the folks that we care about.

Tony: Yeah, yeah, that's, that's really great. And I think it'll look different in different places. And like you say, that, you know, [02:31:00] not, there's no one, one thing, but I, think, yeah, we've, already hearing a lot of excitement about, the ability not only to provide that broad, workforce training, but also, you know, specialized training in a, an effective treatment.

So thanks, looking forward to continuing that work with you and, and, yeah, grateful for the opportunity.

David Jobes: Me too, Tony.