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Assessing and Treating Different Suicidal States in a Danish Outpatient Sample


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The studies presented compare two methodologies for categorizing suicidal patients based on clinical data. Discussion follows regarding implications for risk assessment and treatment. In these studies, 52 outpatient subjects were placed into different groups based on coding their "suicidal motivation" (Study 1) and their "internal struggle" ratings (Study 2) using data collected at intake. Self-report ratings of 6 Suicide Status Form (SSF) Core Constructs (Psychological Pain, Stress, Agitation, Hopelessness, Self-Hate, and Overall Risk of Suicide) recorded both at intake and at completion of treatment were then compared to determine differences in Core Construct ratings among groups at different time points. In Study 1, overall differences among motivation groups (Life-motivated, Ambivalent, and Death-motivated) were significant for ratings at treatment completion of Overall Risk of Suicide, Self-Hate, and Psychological Pain. In Study 2, overall differences among groups (Wish to live, Ambivalent, and Wish to die) were significant for ratings at intake of Overall Risk of Suicide. At completion of treatment, overall differences among groups were significant for ratings of Overall Risk of Suicide, Hopelessness, and Self-Hate. In addition, significant interactions were found between test time and group for Overall Risk of Suicide and Self-Hate. Results suggest that categorizing suicidal patients by motivation and by the nature of their internal struggle could be beneficial to differential risk assessment with implications for clinical treatment.
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USUI #777002, VOL 17, ISS 3
Assessing and Treating Different
Suicidal States in a Danish
Outpatient Sample
Christopher D. Corona, David A. Jobes, Ann C. Nielsen,
Christian M. Pedersen, Keith W. Jennings, Rene
M. Lento, and
Katherine A. Brazaitis
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Assessing and Treating Different Suicidal States in a Danish Outpatient Sample
Christopher D. Corona, David A. Jobes, Ann C. Nielsen, Christian M. Pedersen, Keith W.
Jennings, Rene
M. Lento, and Katherine A. Brazaitis
Assessing and Treating
Different Suicidal States
in a Danish Outpatient
Christopher D. Corona, David A. Jobes, Ann C. Nielsen,
Christian M. Pedersen, Keith W. Jennings, Rene
M. Lento, and
Katherine A. Brazaitis
The studies presented compare two methodologies for categorizing suicidal patients
based on clinical data. Discussion follows regarding implications for risk assessment
and treatment. In this study, 52 outpatient subjects were placed into different groups
based on coding their ‘‘suicidal motivation’’ (Study 1) and their ‘‘internal struggle’’
ratings (Study 2) using data collected at intake. Self-report ratings of 6 Suicide Status
Form (SSF) Core Constructs (Psychological Pain, Stress, Agitation, Hopelessness,
Self-Hate, and Overall Risk of Suicide) recorded both at intake and at completion
of treatment were then compared to determine differences in Core Construct ratings
among groups at different time points. In Study 1, overall differences among motivation
groups (Life-motivated, Ambivalent, and Death-motivated) were significant for rat-
ings at intake of Overall Risk of Suicide, Self-Hate, and Psychological Pain. In Study
2, overall differences among motivation groups (Wish to live, Ambivalent, and Wish
to die) were significant for ratings at intake of Overall Risk of Suicide. At completion
of treatment, overall differences among motivation groups were significant for ratings of
Overall Risk of Suicide, Hopelessness, and Self-Hate. In addition, significant inter-
actions were found between test time and motivation group for Overall Risk of Suicide
and Self-Hate. Results suggest that categorizing suicidal patients by motivation and by
the nature of their internal struggle could be beneficial to differential risk assessment
with implications for clinical treatment.
Keywords internal struggle, motivation, suicide, typology
The prevalence of suicidal ideation and
behavior both in the United States and
abroad supports the argument that suicide
is a legitimate public health concern. The
Substance Abuse and Mental Health
Services Administration (SAMHSA, 2009)
reported that, in 2008, an estimated 8.3
million adults (3.7% of the population aged
18 years and older) experienced suicidal
ideation, 2.3 million (1.0%) made a plan
to attempt suicide, and 1.1 million (0.5%)
actually attempted suicide. Moreover,
the Centers for Disease Control and
Prevention (CDC, 2010) reported that
Archives of Suicide Research, 17:1–11, 2013
Copyright # International Academy for Suicide Research
ISSN: 1381-1118 print=1543-6136 online
DOI: 10.1080/13811118.2013.777002
3b2 Version Number : 7.51c/W (Jun 11 2001)
File path : p:/Santype/Journals/TandF_Production/Usui/v17n3/USUI777002/USUI777002.3d
Date and Time : 07/06/13 and 20:32
almost 37,000 suicides were completed in
2009, making suicide the tenth leading
cause of death across all age groups in
the United States that year.
Worldwide, the numbers are just as
striking. The World Health Organization
(WHO, 2002) reported that approximately
849,000 people died from suicide in 2001.
According to Nordentoft (2007), in
addition to being among the top ten causes
of death worldwide, suicide is also the
second leading cause of non-illness-related
death. In Denmark specifically, the suicide
rate was among the highest in Europe in
1980. Though the suicide rate in Denmark
has declined since then, it is still higher
than that of other Scandinavian countries
and than that of most other Western
European nations (Nordentoft, 2007).
These statistics underscore the need
for effective methods that can both identify
suicide risk and provide treatment for those
most at risk for completing suicide. Nock,
Borges, Bromet et al. (2008) identified
consistencies among risk factors within a
sample drawn from 17 different nations.
These risk factors include being female,
being younger, receiving fewer years of
education, being unmarried, and being
diagnosed with a mental disorder. Diagnos-
tically, the risk factor most associated
with suicide in high-income countries was
the presence of a mood disorder, while in
low-income countries the presence of an
impulse control disorder was the strongest
risk factor. Additionally, Nock and collea-
gues found that, among all countries
included in their study, approximately
60% of the progressions of suicidal beha-
vior from ideation to attempt occurred
during the first year after onset of ideation.
Despite these consistencies in world-
wide risk factors for suicidal behavior, the
ways in which suicidal thoughts manifest
(i.e., their specific content) can be quite
nuanced. Jobes et al. (2004) highlighted
this point in a study that compared
qualitative data from two samples of
suicidal outpatients, one comprised of
college students and the other consisting
of active duty United States Air Force per-
sonnel. Participants were asked to provide
qualitative responses to five suicide-relevant
stimulus prompts, and significant between-
group differences were found when parti-
cipants reported on their experience of
psychological pain and perturbation. The
student responses were suggestive of
developmental struggles that pertained to
identity and relationships, while Air Force
personnel responses were suggestive of
situation-specific crises that centered on
hardships associated with military life. What
is notable in this finding is that the same
stimulus prompt elicited different qualitat-
ive content in each sample, suggesting
that the etiology of suicidal behavior can
vary widely.
Variability has also been found when
examining the extent to which suicidal indi-
viduals have either a wish to live or a wish to
die. Kovacs and Beck (1977) used ratings of
these wishes as the foundation for develop-
ing the ‘‘Internal Struggle Hypothesis,’’
which posited that the risk for suicide is
lower in individuals who have simultaneous
desires to live and to die when compared to
those individuals who have only a wish to
die. This hypothesis was based on a study
that analyzed suicidal risk among parti-
cipants hospitalized in the wake of a suicide
attempt. Approximately 50% of the sample
experienced an internal debate between life
and death as indicated by two self-report
items that asked participants to rate their
wish to live and their wish to die on interval
scales. Patients who expressed both a wish
to live and a wish to die scored lower on a
measure of suicidal intent than patients
who expressed only a wish to die. Brown,
Steer, Henriques, and Beck (2005) used a
similar methodology to assess suicidal risk
among psychiatric outpatients. They com-
bined interval scale ratings of two items
(the Wish to Live and the Wish to Die) to
create an ambivalence index score for each
Assessing and Treating Different Suicidal States
patient, and found that this index score was
significantly associated with prospective
suicidal risk. More specifically, those with
a higher index score (indicating a stronger
wish to die) were at a higher risk for suicide.
This finding supports the Internal Struggle
Hypothesis, and suggests that patient
wishes as they pertain to living and dying
may hold information that could be key to
accurately identifying future suicidal risk.
Given the growing body of literature
that supports suicidality as a multidimen-
sional construct that operates differently
in different individuals, the development
of more nuanced methods for assessing sui-
cidal risk is indicated. The present studies
attempt to further explore the relationship
between motivation, internal struggle, and
suicidal risk in a Danish sample. Two separ-
ate methodologies were used to categorize
participants seen at two outpatient com-
munity mental health centers in Denmark
based on their so called ‘‘suicidal motiv-
ation’’ and the nature of their wish to live
vs. wish to die internal struggle. To this
end, various analyses were run to assess
differences between groups on measures
of suicidal risk both before and after treat-
ment. Results will be discussed with an
emphasis on the potential utility of these
categorization methods in relation to asses-
sing risk with potential implications for
treating suicidal patients therein.
The studies presented were conducted
with a sample of 52 outpatients seen at
one of two community mental health
centers in Aarhus and Copenhagen. The
mean age of the sample was 28.33 years,
with a range of 15 to 54 years. 73.1% of
the sample was female; 90.4% was of
Danish ethnicity; 69.2% was single; 63.5%
were either employed or working towards
a degree; 67.3% had not received previous
mental health treatment of any kind at any
time; and 59.6% had not made a suicide
attempt at the time of referral. It should
be noted that being without a suicide
attempt at referral does not imply that a
suicide attempt had never been made.
Demographic data about suicidal behavior
prior to referral was not available. Subjects
included in the study were those that had
either attempted suicide or expressed suici-
dal ideation at the time of referral. Subjects
excluded from the study were those that
were already receiving mental health treat-
ment elsewhere, as well as those with major
or chronic mental disorders (including
major depressive disorder, bipolar disorder,
and schizophrenia), substance abuse or
dependence, personality disorders, and
attention deficit hyperactivity disorder.
The instrument used in both studies
was the Suicide Status Form (SSF), which
is the primary assessment, treatment plan-
ning, and tracking tool used in the ‘‘Colla-
borative Assessment and Management of
Suicidality’’ (CAMS). Developed by Jobes
(2006), CAMS is a therapeutic framework
that clinicians from any theoretical back-
ground can adapt to their treatment style
when addressing suicidality. The approach
is founded upon the formation of a strong
alliance between clinician and patient, which
encourages the clinician to acknowledge
the patient’s suicidal wish as well and
encourages the patient to be an active par-
ticipant in his or her own risk assessment,
treatment planning, and outcomes tracking.
There is an evolving evidence base showing
solid support for the effectiveness of CAMS
in reducing suicidal constructs (Arkov,
Rosenbaum, Christiansen, Jonsson, &
Munchow, 2008; Ellis, Green, Allen, Jobes,
& Nadorff, 2012; Jobes, Kahn-Greene,
Greene, & Goeke-Morey, 2009; Nielsen,
C. D. Corona et al.
Alberdi, & Rosenbaum, 2011) and improv-
ing the therapeutic experience (Arkov,
Rosenbaum, Christiansen et al., 2008;
Comtois, Jobes, O’Connor et al., 2011; Ellis,
Green, Allen et al., 2012). Additionally,
comparison control studies have shown
CAMS to be superior to treatment-as-usual
with regard to resolving suicidality in both
randomized (Comtois, Jobes, O’Connor
et al., 2011) and non-randomized clinical
trials (Jobes, Wong, Conrad et al., 2005).
The SSF is used throughout CAMS to
assess and track useful clinical data regard-
ing a patient’s suicidality, and it has been
psychometrically studied and found to be
a valid and reliable clinical assessment
measure for suicidal risk (Conrad, Jacoby,
Jobes et al., 2009; Jobes, Jacoby, Cimbolic
et al., 1997). Previous research also supports
the ability of the SSF to predict treatment-
related changes in suicidality over the
course of clinical treatment (Jobes, Kahn-
Greene, Greene et al., 2009), and categorize
suicidal patients with implications for
treatment outcomes (Jobes, Jacoby,
Cimbolic et al., 1997; Jobes, Nelson,
Peterson et al., 2004).
Three key elements of the SSF are the
focus of the present studies. The first
element consists of written Reasons for
Living (RFL) and Reasons for Dying
(RFD) responses. At intake, patients are
asked to write down up to five Reasons
for Living and up to five Reasons for
Dying, and then asked to rank each RFL
and RFD from 1 to 5 (a score of 1 indicates
the reason that is of most importance to the
patient). The second element (also com-
pleted at intake) consists of two items that
ask the patient to rate on a Likert scale
(from 0–8 with higher scores indicated
higher intensity) their respective Wish to
Live and their Wish to Die.
The third element consists of six self-
rated ‘‘Core SSF Constructs’’ (Psychologi-
cal Pain, Stress, Agitation, Hopelessness,
Self-Hate, and Overall Risk of Suicide) that
serve to assist in the assessment of suicidal
risk and in tracking outcomes. Patients are
asked to rate the severity of each construct
on a Likert scale (from 1 to 5 with higher
scores indicating higher intensity). Then,
with the exception of Overall Risk of
Suicide, patients are asked to rank the
importance of the first five constructs from
1to5(1¼ most important;5¼ least important).
Traditionally, these SSF Core Constructs
are assessed at intake, at the start of each
CAMS tracking session, and in the final
CAMS session. In the present studies, the
SSF Core Construct ratings were only avail-
able for each subject from intake and from
their final CAMS session. The number of
CAMS sessions for all subjects ranged from
2 to 11, with the average treatment cycle
lasting 5.52 sessions.
Study 1
The first study used a ‘‘macro-coding’’
methodology to categorize subjects by sui-
cidal motivation according to the number
of written RFL and RFD responses
recorded on the SSF at intake. Support for
this methodology comes from Jobes and
Mann (1999), who found significant
quantitative differences in RFL and RFD
responses in a sample of suicidal university
counseling center patients, and posited that
suicidal risk may be higher for those with
fewer Reasons for Living. For each subject,
the total number of RFD responses was
first subtracted from the total number of
RFL responses. Subjects were then categor-
ized based on the value obtained using
this calculation. Those subjects with a posi-
tive value (indicating more written RFL
responses on the SSF) were place in the
‘‘Life-motivated’’ (Life-M) group; those
subjects with a negative value (indicating
more written RFD responses) were
placed in the ‘‘Death-motivated’’ (Death-M)
group; and those with a value of zero
(indicating an equal number of written
RFL and RFD responses) were placed in
the ‘‘Ambivalent’’ (Ambiv) group.
Assessing and Treating Different Suicidal States
The primary research question in this
study asked whether categorizing patients
according to suicidal motivation could be
related to differences in SSF Core Construct
ratings at intake and at completion of treat-
ment. Comparisons were made using motiv-
ation group as the independent variable and
each of the six SSF Core Constructs as
dependent variables. First, six one-way
Analysis of Variance (ANOVA) tests were
run to assess differences among motivation
groups on each Core Construct rating at
intake. Six additional one-way ANOVAs
were then run comparing construct ratings
by motivation group at completion of treat-
ment. Finally, six repeated-measures ANO-
VAs were run to detect any interactions
between assessment time (intake and com-
pletion of treatment) and motivation group
when comparing Core Construct ratings.
Follow-up contrasts were run on significant
overall models to test for specific between-
group differences.
Study 2
The second study categorized subjects
by the nature of their internal struggle
according to responses to SSF items asking
patients to rate their Wish to Live and Wish
to Die at intake. Each subject’s responses
were first converted to a 3-point scale.
Ratings from 0–2 were assigned a value of
0, ratings from 3–5 were assigned a value
of 1, and ratings from 6–8 were assigned a
value of 2. This conversion was done to
adapt the Wish to Live and Wish to Die
scales found on the SSF to be more aligned
with those found on the Scale for Suicide
Ideation (Beck, Kovacs, & Weissman,
1979). The converted Wish to Die score
was then subtracted from the converted
Wish to Live score, allowing for the
calculation of a ‘‘Suicide Index Score’’ with
values ranging from 2 to 2. Support for
this methodology comes from Brown,
Steer, Henriques et al. (2005), who found
that an index score with similar intervals
was associated with suicidal risk. A notable
difference between their methodology and
the one presented here is that positive SIS
values in this study indicated a stronger
wish to live. Finally, subjects were placed
into one of three motivation categories
based on SIS. Those with scores of 2
or 1 were placed in the ‘‘Wish-to-die’’
(WTD) group; those with a score of 0 were
placed in the ‘‘Ambivalent’’ (AMB) group;
and those with scores of 1 or 2 were place
in the ‘‘Wish-to-live’’ (WTL) group.
The same analyses conducted in Study
1 were also run in Study 2. In addition to
asking whether categorizing patients
according to either suicidal motivation or
the nature of their internal struggle is
related to differences in SSF Core Con-
struct ratings, another research goal was
to compare and contrast results garnered
from each methodology.
Study 1
This categorization methodology
resulted in a frequency distribution of 36
(69.2%) subjects in the Life-M group, 9
(17.3%) subjects in the Ambiv group, and
7 (13.5%) subjects in the Death-M group.
One-way ANOVAs found no significant
differences among motivation groups on
any of the SSF Core Constructs at intake.
Additionally, there were no significant
interactions between assessment time and
motivation group. When comparing SSF
Core Construct ratings at completion of
treatment (Table 1), overall differences
among motivation groups were significant
for ratings of Overall Risk of Suicide
(F ¼ 3.61, p ¼ .035), Self-Hate (F ¼ 3.68,
p ¼ .032), and Psychological Pain
(F ¼ 3.22, p ¼ .048).
Post-hoc pairwise comparisons were
run for both Overall Risk of Suicide and
Self-Hate using a Bonferroni test because
C. D. Corona et al.
of its control of Type I Error rate and
relative power when testing few compari-
sons (Field, 2009). Overall Risk of Suicide
ratings at completion of treatment were
significantly different between the Life-M
(1.31) and Death-M (M ¼ 2.14) groups
(p ¼ .032). When comparing Self-Hate rat-
ings at completion of treatment, significant
differences were found between the Ambiv
(M ¼ 1.89) and Death-M (M ¼ 3.57)
groups (p ¼ .032). Because Levene’s Test
of Equality of Error Variances was signifi-
cant for Psychological Pain (F ¼ 4.61,
p ¼ .015), post-hoc pairwise comparisons
were run for this construct using
Tamhane’s T2 test. This test is known for
its consistent conservatism when variances
are unequal (Jaccard, Becker, & Wood,
1984). No significant differences were
found between pairs of motivation groups
when comparing Psychological Pain ratings
at completion of treatment.
Study 2
This methodology produced a fre-
quency distribution of 33 (63.5%) subjects
in the WTL group, 13 (25%) subjects in
the AMB group, and 6 (11.5%) subjects
in the WTD group. When comparing
Core Construct ratings at intake, overall
differences among motivation groups were
significant for Overall Risk of Suicide
(F ¼ 13.61, p ¼ < .001). At completion of
treatment (Table 2), overall differences
among motivation groups were significant
for ratings of Overall Risk of Suicide (F ¼
10.77, p < .001), Hopelessness (F ¼ 3.94,
p ¼ .026), and Self-Hate (F ¼ 4.83,
p ¼ .012). Unique to Study 2 were signifi-
cant findings when using repeated-
measures ANOVAs to compare construct
ratings across test times by motivation
group. Significant interactions were found
between test time and motivation group
for Overall Risk of Suicide (F ¼ 4.31,
p ¼ .019) and Self-Hate (F ¼ 4.40, p ¼ .018).
A post-hoc Bonferroni test found
significant differences in Overall Risk of
Suicide ratings at intake between the WTL
(M ¼ 1.76) group and both the AMB
(M ¼ 3.04) group (p < .001) and the WTD
(M ¼ 3.33) group (p ¼ .001). Post-hoc com-
parisons were run using Tamhane’s T2 test
for Overall Risk of Suicide at treatment
completion due to a significant Levene’s
test (F ¼ 9.91, p < .001), and a significant
difference was found between the WTL
(M ¼ 1.12) and AMB (M ¼ 2.15) groups
(p ¼ .014). For ratings of Hopelessness
at completion of treatment, a post-hoc
Bonferroni test found a significant difference
TABLE 1. Study 1
Ratings at treatment completion (Mean)
SSF core construct Life-M Ambiv Death-M
Psychological Pain
2.44 1.89 3.57
Stress 2.67 2.33 3.00
Agitation 2.61 1.89 3.43
Hopelessness 2.31 1.56 3.14
2.42 1.89
Overall Risk of Suicide
1.33 2.14
Note. Groups presented in this table were derived by subtracting the total number of Reasons For Dying
responses from the total number of Reasons For Living responses for each subject.
Significant difference from one other group within the same Suicide Status Form (SSF) Core Construct.
Overall model significant at p < .05.
Assessing and Treating Different Suicidal States
between the WTL (1.91) and the AMB
(3.00) groups (p ¼ .039). Significant
differences in Self-Hate ratings at treatment
completion between the WTL (2.09) and
the AMB (3.31) groups (p ¼ .012) were
also found after conducting a post-hoc
Bonferonni test.
Both methodologies described were used in
an attempt to categorize suicidal individuals
and to determine whether such categoriza-
tions were able to detect differences in
initial assessments and in treatment out-
comes. The first study categorized subjects
by suicidal motivation based on qualitative
written Reasons for Living and Reasons
for Dying as recorded at intake. Results
indicated that self-rated Overall Risk of
Suicide at treatment completion increases
in intensity across the three constructs,
from the Life-motivated to Ambivalent to
Death-motivated groups. For the other five
SSF Core Constructs (Psychological Pain,
Stress, Agitation, Hopelessness, and Self-
Hate), subjects in the Ambivalent group gave
the lowest ratings at treatment completion,
whereas those in the Death-motivated group
gave the highest ratings. This suggests that
the magnitude of emotional upset within
subjects in the different motivation groups
does not mirror their own interpretations
of suicidal risk. This finding supports
results from O’Connor, Jobes, Lineberry,
and Bostwick (2010) suggesting that, in
addition to the magnitude of emotional
upset, the specific ways in which this upset
is experienced in suicidal individuals could
also be indicative of risk. Also suggested
by these results is the protective role of
Reasons for Living both when they pre-
dominate and whey they are serving as a
buffer against an equal number of Reasons
for Dying. This interpretation is aligned
with findings from Linehan, Goodstein,
Nielsen, and Chiles (1983) indicating that
self-assessment of suicidal risk is negatively
correlated with a connection to reasons for
staying alive. Similarly, Jobes and Mann
(1999) posited that Reasons for Living
could serve as a critical focus point for
clinicians when treating suicidal patients.
Study 2 categorized subjects by the nat-
ure of their internal struggle using quantitat-
ive ratings of their Wish to Live vs. their
Wish to Die as recorded at intake. For
Overall Risk of Suicide, ratings at intake
followed the same progression as those at
TABLE 2. Study 2
Ratings at treatment completion (Mean)
SSF core construct WTL AMB WTD
Psychological Pain 2.21 3.00 3.00
Stress 2.42 3.08 3.00
Agitation 2.27 3.31 2.83
Overall Risk of Suicide
Note. Groups presented in this table were derived by calculating a Suicide Index Score (subtracting
the converted Wish to Die score from the converted Wish to Live score) for each subject.
Significant difference from one other group within the same Suicide Status Form (SSF) Core
Overall model significant at p < .05.
Overall model significant at p < .001.
C. D. Corona et al.
treatment completion in Study 1 (i.e., an
increase in intensity as one either is domi-
nated by Reasons for Dying or expresses
more of a Wish to Die). At treatment com-
pletion in Study 2, however, subjects in the
Ambivalent group gave the highest ratings,
while subjects in the Wish-to-Live group
gave the lowest. For the other five SSF Core
Constructs, ratings at treatment completion
mirrored this trend (ratings were lowest in
the Wish-to-Live group and highest in the
Ambivalent group), which corresponds
with results found by O’Connor, Jobes,
Yeargin et al. (2011) suggesting that
Ambivalent patients fare the worst on cer-
tain measures related to suicidality. Also
unique to Study 2 was a significant interac-
tion between motivation group and assess-
ment time when measuring Overall Risk
of Suicide. At intake, the Wish-to-die group
provided the highest ratings, whereas the
Ambivalent group rated this construct high-
est at treatment completion. This finding
suggests that these two groups responded
differently to treatment. More specifically,
the implication is that suicidal risk in the
Ambivalent group dissipated less over time
than it did in the Wish-to-die group.
A possible interpretation of the results
from Study 2 suggests that a Wish to Die
is most associated with risk when operating
in conjunction with a Wish to Live of the
same magnitude, and that risk as measured
by these items is mitigated as the Wish to
Die decreases and the Wish to Live
increases. This interpretation seems to con-
tradict the Internal Struggle Hypothesis by
suggesting that the existence of a debate
between the Wish to Live and the Wish to
Die could be a risk factor for suicide in
and of itself. This implication is supported
by findings from Harris, McLean, Sheffield,
and Jobes (2010) indicating that, among
survey respondents, the vast majority
(94.5%) of those most suicidal reported
experiencing a debate between the wish to
live and the wish to die. These findings also
suggest that the presence of such a debate is
correlated with increased suicidal risk.
While the exact mechanism for contradic-
tion with the internal struggle hypothesis
is not clear, it is worth addressing the
potential existence of a sample more at risk
for a non-fatal suicide attempt than for a
completed suicide. Existing literature sug-
gests the relatively low lethality of suicide
attempts made by females compared to
those made by men (Moscicki, 1994). Given
that the sample studied here was predomi-
nantly female (73.1%), it could be posited
that the ambivalence expressed by this
group is potentially more indicative of risk
for a non-fatal suicide attempt.
In general, suicidal risk as it pertains to
the sample studied was highest in those
dominated by Reasons for Dying and strug-
gling with the debate between a Wish to
Live and a Wish to Die. This conclusion
further validates existing literature suggest-
ing the protective potential of Reasons for
Living (Linehan, Goodstein, Neilen et al.,
1983; Jobes & Mann, 1999; Malone,
Oquendo, Haas et al., 2000; Lizardi, Currier,
Galfalvy et al., 2007). Furthermore, the
methodologies presented here highlight
means through which these constructs can
be efficiently assessed in a clinical setting,
and subsequently written into treatment
plans as an important focus. For example,
a possible interpretation suggests that an
emphasis on cultivating Reasons for Living
could not only buffer against the presence
of Reasons for Dying, but could also serve
as a potential avenue for mitigating both a
proclivity to death and the internal struggle
experienced by ambivalent patients. As the
evidence base grows regarding acute risk
factors for suicide, developing methods
for translating these findings into effective
clinical practice remains imperative.
Given the differences in results, it is
reasonable to posit that the two methodol-
ogies presented here could be measuring
overlapping but still separate constructs as
it pertains to what is driving suicidal desire,
and that each construct could provide
Assessing and Treating Different Suicidal States
information that is useful in a clinical
context. It is worth nothing that one
fundamental difference between these two
constructs is the means through which data
pertaining to each is collected. Reasons for
Living and Reasons for Dying are both
reported qualitatively by patients, while
the Wish to Live and the Wish to Die are
both reported quantitatively. While the
methodology used in Study 1 presented a
means through which to quantify Reasons
for Living and Reasons for Dying, it is
not clear what might be lost in such a trans-
lation or what the implications of such a
loss might be for comparison of these con-
structs. Given the widespread collection of
both qualitative and quantitative data in
clinical settings, further research should
continue to investigate the ways in which
these types of data interact with specific
emphasis on assessing suicide risk. Such
research should also include special atten-
tion to known differences among those
are likely to make non-fatal suicide attempts
versus those who are likely to complete sui-
cide, with an emphasis on the ways in
which risk for different outcomes might
present similarly in clinical settings.
Limitations of the studies include the
relatively small sample size (limiting statisti-
cal power) and a skewed distribution of
subjects across motivation categories.
Specifically with regard to statistical power,
it is possible that a larger sample size would
have yielded additional differences in SSF
Core Construct ratings at intake across
studies. It is important to differentiate
between an underpowered study and the
conceptual implication that the groups
studied do not differ at intake. A larger
sample size would be necessary to further
elucidate the nature of these differences.
Taken from outpatient community men-
tal health centers, the sample analyzed was
weighted heavily towards Life-motivated
and Wish-to-live subjects. Furthermore,
existing evidence suggests that previous hos-
pitalization for a major psychiatric illness is
among the most predominant risk factors
for suicide in both men and women in
Denmark (Qin, Agerbo, Westergard-Nielsen
et al., 2000). Our studies, in turn, excluded
those who would likely present with the
highest risk for suicide, which has the poten-
tial to skew results pertaining to the assess-
ment of such risk. Additionally, a lack of
background information pertaining to sub-
jects’ history of suicidal ideation and beha-
vior before referral limited the ability to
control for potential confounding factors in
this regard. These factors limit the external
validity of the studies presented.
There is an evidence base that supports
the mitigation of suicidal risk both through
the development of meaningful connec-
tions to Reasons for Living and through a
reduction in the Wish to Die, however the
explicit connection between these avenues
is not fully understood. Further research
into both the nature of these constructs as
they are measured today and their interplay
is necessary before the nuances of the suici-
dal mind can be fully understood, and
before such knowledge can provide maxi-
mal clinical benefit to those most in need.
The authors have no potential conflicts of
interest to disclose. Additionally, no finan-
cial agreements or affiliations exist with
any institution, product, or service that
could be interpreted as influencing this
research, nor is there any bias expressed
against another institution, product, or
Christopher D. Corona and David A.
Jobes, The Catholic University of America,
Washington, D.C., USA.;
Ann C. Nielsen, Psykiatrisk Center
København, Kompetencecenter for Selv-
mordsforebyggelse, Copenhagen, Denmark.
Christian M. Pedersen, Klinik for
Selvmordsforebyggelse, Aarhus Universi-
tetshospital Risskov, Aarhus, Denmark.
C. D. Corona et al.
Keith W. Jennings, Rene´ M. Lento, and
Katherine A. Brazaitis, The Catholic Uni-
versity of America, Washington, D.C., USA.
Correspondence concerning this article
should be addressed to Christopher D.
Corona, M.A. Department of Psycholo gy,
The Catholic University of America, O’Boyle
Hall, Room 314 Washington, DC 20064.
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... In subsequent research using this simple equation (that was a later called a "suicide index score"), Brown, Steer, Henriques, and Beck (2005) found significant odds ratios for suicidal behaviors associated with the wish-to-die subtype based on a one-time index rating of these constructs. Additional research has further replicated reliable subtypes of suicidal states using this cross-sectional trichotomy assessment methodology based on index wish-to-live and wish-to-die patient self-reports (Corona et al., 2013;O'Connor et al., 2012). ...
... These authors argue that such scales have no predictive validity, therefore we must completely eschew this whole approach altogether. While we have known for many years that we cannot predict low base-rate phenomena like suicide (Murphy, 1983), others have argued that thinking about relative suicidal risk and different kinds of suicidal states is a compelling endeavor that can directly help inform our clinical treatments for suicidal risk (e.g., Corona et al., 2013). ...
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There is a significant need to improve clinical practices related to suicidal patients within contemporary mental health practice. It is argued that there is a general over-reliance on psychotropic medications and the use of inpatient psychiatric hospitalizations for suicidal risk. This reliance is puzzling given the lack of empirical support for these approaches; the evidence supporting the use of psychotropics is mixed and there are recent challenges to the routine use of inpatient care that tends not to be suicide-specific and may increase post-discharge risk. Importantly there are several psychological treatments proven effective in rigorous randomized controlled trials (RCTs). Of the replicated RCTs, dialectical behavior therapy (DBT), two forms of suicide-specific cognitive-behavioral therapy—cognitive therapy for suicide prevention (CT-SP) and brief cognitive behavioral therapy (BCBT)—and the collaborative assessment and management of suicidality (CAMS) have shown robust data for effectively treating suicidal risk. But despite the data these treatments are not widely used. Possible reasons for an inadequate professional response to suicidality may include: (a) countertransference, (b) fear of malpractice litigation, (c) lack of knowledge about suicide risk assessment, and (d) lack of knowledge about effective treatment for suicidal risk. CAMS is discussed as a possible remedy for the professional and clinical issues raised in this article.
... The Overall Risk score is a single item which asks each patient to rate their relative risk of death by suicide in the future on a scale from 1 (extremely low risk) to 5 (extremely high risk). While a single-item relative risk score has inherent limitations, extant literature suggests that relative risk indicators can effectively distinguish between life and death orientation during treatment and appropriately correspond to changes in these orientations over the course of treatment for STB (Corona et al., 2013;Jobes, 2016;O'Connor et al., 2012). Accordingly, the five variables of the Core Assessment were summed to yield a total score for each patient, which were then mean centered. ...
The Suicide Status Form-IV (SSF-IV) is the measure used in the Collaborative Assessment and Management of Suicidality (CAMS). The SSF-IV Core Assessment measures various domains of suicide risk. Previous studies established a two-factor solution in small, homogeneous samples; no investigations have assessed measurement invariance. The current investigation sought to replicate previous factor analyses and used measurement invariance to identify differences in the Core Assessment by race and gender. Adults (N = 731) were referred for a CAMS consultation after exhibiting risk for suicide. Confirmatory factor analyses indicated good fit for both one- and two-factor solutions while the two-factor solution is potentially redundant. Configural, metric, and scalar invariance held across race and gender. Ordinal logistic regression models indicated that neither race nor gender significantly moderated the relationship between the Core Assessment total score and clinical outcomes. Findings support a measurement invariant, one-factor solution for the SSF-IV Core Assessment.
... Схема ABC была уточнена в модели суицидального барометра (SBM) [14], используемой для оценки суицидального риска (рисунок 2). Она основана на эмпирических доказательствах того, что самоубийство является изменчивым состоянием, это имеет серьезные последствия для оценки как текущего личного риска суицида, так и будущего [15]. ...
Abstract: In the article we analyze current trends in the suicide risk studies and the development of strategies for suicide prevention in Russia and around the world. Basing on modern studies, we consider he the structure of suicidal risk to include affective, cognitive and behavioral characteristics. In the paper we present the concept of increasing potential risk factors and risk predicators developed by M. D. Rudd, A. L. Berman, T. E. Joiner, M. K. Nock, M. M. Silverman, M. Mandrusiak, K. Van Orden, and T. Witte, also we analyze the theory of suicidal barometer developed by K. M. Harris, J. Syu, O. D. Lello, Y. L. Chew, C. H. Willcox, R. H. Ho. In addition, we analyze the concept of historiograph suicidal behavior, L. N. Iourieva, a model of suicidal behavior A. G. Abramovay. Also we present our author's conception of the components of suicide prevention.
... Qualitative responses recorded during the course of CAMSguided care have also shown promise with regard to categorizing suicidal patients according to their experience of ambivalence about suicide (Jobes, 2012). For example, Corona et al. (2013) used a sample of suicidal Danish outpatients receiving CAMS to compare the number of Reasons for Living responses with the number of Reasons for Dying responses provided by each patient. This comparison allowed for patients to be categorized as Life-motivated, Ambivalent, or Death-motivated. ...
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The current study replicates a previously used methodology with a suicidal inpatient sample regarding word counts generated by participants writing about suicidal constructs. Word counts (i.e., the number of written words) on the Suicide Status Form from initial sessions with suicidal inpatients were compared to self-rated suicide risk scores as well as to continuous and repeated measures of hopelessness and suicide ideation assessed over the course of inpatient care. Results showed that higher word counts were associated with initially higher suicide ideation scores that steadily declined over the course of treatment. Lower word counts were associated with lower initial hopelessness scores that increased during treatment before ultimately decreasing. In addition, word count was not found to be a significant predictor of self-rated suicide risk. Clinical implications of these data and future directions are discussed.
... The data derived from Denmark were from outpatients seen at one of two community mental health centers in Aarhus and Copenhagen. Participants who were already receiving CAMS care were included in this project (for more details, see Corona et al., 2013). ...
Background: In this article we focused on analyzing surveyed patient-generated responses based on two outcome questions derived from a suicide-specific framework called the Collaborative Assessment and Management of Suicidality (CAMS): Q1 - "Were there any aspects of your treatment that were particularly helpful to you? If so, please describe these. Be as specific as possible." Q2 - "What have you learned from your clinical care that could help you if you became suicidal in the future?" Aims: To develop a reliable coding system based on formerly suicidal patients' responses to two open-ended prompts and examine most frequently identified themes. Method: The present study utilized a consensual qualitative research process to examine responses of clinically resolved suicidal patients, based on the CAMS resolution criteria (i.e., three consecutive CAMS sessions reporting the effective management of suicidal risk), to two Suicide Status Form (SSF) outcome questions (n = 49 for Q1, and n = 52 for Q2). Results: Reliable coding systems were developed and used to determine major themes of successful patient responses. Conclusion: The results of this study provide insight into patients' experiences of a successful treatment for suicidal risk with larger implications for suicide-specific treatments in general.
... As discussed elsewhere [33], an evolving Bstepped-care^model for treating suicidal risk may well emerge in the coming years that creates a continuum of clinical care ranging from the paraprofessional and peer-based support, to suicide-specific care involving brief interventions, as well as suicidespecific outpatient, partial, and respite clinical care. Likewise, there is an emerging interest in stratifying the risk of different suicidal states with the potential for matching different kinds and doses of treatments to different suicidal states [34,35]. Given the known high risk of suicide that follows inpatient discharge [36], inpatient psychiatric care will increasingly need to embrace the use of suicide-specific interventions during an inpatient stay with an emphasis on safety planning and postdischarge means-restriction along with thoughtful disposition planning that bridges a patient to effective outpatient care. ...
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Opinion statement In recent decades, the sub-specialization of “clinical suicidology” emphasizing suicide risk assessment, treatment, training, and the management of suicide-related liability has grown exponentially. This line of thinking had led to the development of suicide-specific treatments that target suicide as the focus of care (vs. a primary focus on treating mental disorders). These treatments are being extensively investigated using randomized controlled clinical trials to prove their efficacy and effectiveness. This article features the three main replicated treatments for suicide: Dialectical Behavior Therapy, Cognitive Therapy for Suicide Prevention, and the Collaborative Assessment and Management of Suicidality. In addition, there is a recent surge of brief suicide-focused interventions (1–4 sessions) that include variations of stabilization planning and close examination of suicide attempts as an opportunity to learn about suicidal risk with coping-oriented guidance and support. Within a rapidly evolving contemporary mental health care reality, these suicide-related treatments and interventions hold great promise for the prospect of providing more effective (and potentially life-saving care) for suicidal patients.
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Context: The will to live is an important factor to consider in the context of providing resource-oriented palliative care. Until now, there has been no major review of the existing research on this subject. Objectives: The primary objective of this study is to summarize the state of research concerning instruments that assess the will to live. The secondary objective is to explore the theoretical models and psychometric properties of these instruments, in studies where these instruments were initially presented. The tertiary objective is to identify, among all studies where these instruments have been used, the intensity of the will to live and factors associated with it. Methods: We conducted a scoping review, including studies that were designed to assess the will to live among participants in all settings. Records were systematically searched from seven bibliographic databases with no date limitations up to August 2020. Results: Of the 3078 records screened, 281 were examined in detail and 111 were included in the synthesis. A total of 25 different instruments quantitatively assessing the will to live are presented. Most are single-question tools and rate intensity. The underlying concepts and psychometric properties are incompletely explained. Lack of cross-referencing is apparent. The intensity of the will to live is high, even among people with significant health impairment, and is frequently associated with different factors, such as resilience and quality of life. Conclusion: A considerable yet unconnected body of studies assesses the will to live. Its assessment in clinical routine could promote resource-oriented, patient-centered care.
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The research features modern domestic and foreign fundamental approaches to self-destructive behavior and suicidal risk. The author adduces the data on the structure of suicidal risk, its affective, cognitive, and behavioral characteristics. The paper also describes the concept of increasing potential risk factors and predicates presented by M. D. Rudd, as well as an analysis of the theory of suicidal barometer developed by K. M. Harris, J. J. Syu, O. D. Lello, Y. L. Chew, C. H. Willcox, and R. H. Ho. It also features situational and personal factors of suicidal risk, both potential and actual. The paper focuses on predictors of the genesis and development of predisposition to auto-destructive behavior in adolescents.The research objective was to study the characteristics of risk factors of autodestructive behavior in adolescents. The sample group included 116 participants, 14–16-year-old students of 9–10 grades. The author described situational and personal risk factors of auto-destructive behavior in adolescents. They revealed a correlation between personal relations with inner circle and neighborhood society, as well as affective, cognitive, and behavioral personality factors of autodestructive risk.
This chapter describes both the key tenets of Collaborative Assessment and Management of Suicidality (CAMS), as well as lessons learned from clinical trials. CAMS is grounded in a particular therapeutic philosophy that eschews a traditional medical model approach to suicide prevention in which suicidality is relegated to symptom status under the larger umbrella of mental disorders. The suicidology literature is brimming with countless examples where psychopathology is seen to be the etiological basis of suicide. The two patient-identified suicidogenic problems are consequently noted in the Suicide Status Form (SSF) treatment planning section with related objectives and potential interventions that can be used to treat each problem, respectively. Following the work of Ghahramanlou-Holloway, Cox, and Greene, who are investigating an intensive suicide-specific inpatient treatment called Post Admission Cognitive Therapy (PACT), the chapter explores the use of an intensive inpatient version of CAMS.
Background: The "Internal Struggle Hypothesis" (Kovacs and Beck, ) suggests that suicidal persons may have both a wish to live (WTL) and a wish to die (WTD). The current study investigates whether the three-group typology - "WTL", "ambivalent (AMB)", and "WTD" - is determined by common correlates of suicidality and whether these groups can be ordinally ranked. Methods: The sample comprised 113 older inpatients. Discriminant analysis was used to create two functions (combining social, psychiatric, psychological, and somatic variables) to predict the assignment of older inpatients into the groups WTL, AMB, and WTD. Results: The functions "Subjective Well-being" and "Social Support" allowed us to assign patients into these three distinct groups with good accuracy (66.1%). "Subjective Well-being" contrasted the groups WTD and WTL and "Social Support" discriminated between the groups WTD and AMB. "Social Support" was highest in the AMB group. Conclusions: Our results suggest a simultaneous presence of a WTL and a WTD in older inpatients, and also that the balance between them is determined by "Subjective Well-being" and "Social Support". Unexpectedly, the AMB group showed the highest scores on "Social Support". We hypothesize that higher social support might function as an important determinant of a remaining WTL when a WTD is present because of a lower sense of well-being. The study suggests that the groups WTL-AMB-WTD can not situated on a one-dimensional continuum. Copyright © 2016 John Wiley & Sons, Ltd.
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Thesis (doctoral)--Københavns universitet, 2007.
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Reviews the literature on the use of pairwise multiple comparisons in terms of between-S and repeated measures experimental designs and the optimality of experimental conditions. Tests are recommended for use in conditions in which the assumptions of normality, homogeneous population variances, and equal sample sizes are violated. (65 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Two studies addressed assessment and treatment issues pertaining to suicidal student-clients. In Study 1, the theoretical construction and psychometric properties of the Suicide Status Form (SSF) were described. Results suggest that SSF items have good convergent validity, strong criterion-prediction validity, and moderate test-retest reliability. In Study 2, the SSF was applied to a sample of suicidal student-clients. Results suggest differences between client and clinician pretreatment SSF ratings. Client (not clinician) pretreatment SSF ratings could be used to correctly classify clients into acute resolver and chronic nonresolver treatment-outcome groups. Whereas all suicidal student-clients globally improved with treatment, chronic nonresolvers remained suicidally preoccupied throughout the academic year. These findings are discussed with regard to training, clinical practice, and future research. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Patients hospitalized for psychiatric reasons exhibit significantly elevated risk of suicide, yet the research literature contains very few outcome studies of interventions designed for suicidal inpatients. This pilot study examined the inpatient feasibility and effectiveness of The Collaborative Assessment and Management of Suicidality (CAMS), a structured evidence-based method for risk assessment and treatment planning (Jobes, 2006). The study used an open-trial, case-focused design to assess an inpatient adaptation of CAMS, spread over a period averaging 51 days. The intervention was provided via individual therapy to a convenience sample of 20 patients (16 females and four males, average age 36.9) who were hospitalized with recent histories of suicidal ideation and behavior. Results showed statistically and clinically significant reductions in depression, hopelessness, suicide cognitions, and suicidal ideation, as well as improvement on factors considered "drivers" of suicidality. Treatment effect sizes were in the large range (Cohen's d > .80) across several outcome measures, including suicidal ideation. Although these findings must be considered preliminary due to the lack of a randomized control group, they merit attention from clinicians working with patients at risk for suicide. This study also supports the feasibility of implementing a structured, suicide-specific intervention for at-risk patients in inpatient settings.
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Previous studies confirm the effect of collaborative assessment and management of suicidality (CAMS) in an experimental setup, but there is a need to test CAMS with regard to its effectiveness and feasibility in a real-life clinical context. The purpose of this study was to investigate CAMS in a Danish population in such a context. In the present descriptive study, CAMS treatment was administered to a total of 42 patients referred during 1 August 2008 to 30 September 2009 to The Centre of Excellence in Suicide Prevention due to suicidal thoughts or a suicide attempt. Qualitative and quantitative data were obtained before and after CAMS treatment. Five major suicidal markers were regularly assessed. The patients' experiences of the importance of the treatment were studied as endpoints. A total of 81% of the patients completed treatment and 68% hereof completed the final evaluation. 74% from this group judged the sessions to be the main factor in the elimination of their suicidality. A significant decrease was observed in the five suicidal markers recorded for the 42 patients included. One patient attempted suicide and another patient committed suicide. CAMS was assessed to be effective and useful in a real-life clinical context. Further studies in larger patient populations are needed as are studies to determine whether the CAMS method may be applied with equal effect to all patient groups. not relevant. Danish Data Protection Agency.
The Reasons for Living vs. Reasons for Dying (RFL/RFD) Assessment was used to obtain suicidal outpatients' top five reasons for living and for dying, respectively. Forty-nine suicidal university counseling center patients provided 173 RFL and 145 RFD responses. These responses were organized into eight RFL coding categories and nine RFD coding categories. Two coders trained in the RFL/RFD coding system showed high levels of inter-rater reliability (KRFL = .81; KRFD = .80). Chi-square results for RFL and RFD coding categories showed that the coding categories were not equally salient to these suicidal patients.
The aim of this study was to determine the validity of assigning suicidal individuals into differing typologies of suicidality based on their reported wish to live and wish to die. One hundred five inpatients who reported suicidal ideation in the previous 48 hours completed a battery of assessments during inpatient psychiatric hospitalization. An algorithm was used to assign participants into 1 of 3 typologies of suicide: wish to live, ambivalent, or wish to die. Discriminant function analysis and group classification were used to predict group membership, followed by multiple analysis of variance and follow-up contrasts to measure between-group differences. Group classification resulted in 76% accuracy for predicting typology of suicidality based on scores from suicide-specific measures. Self-perceived risk of suicide and hopelessness were the strongest variables at differentiating between the 3 groups. Patients in the wish to die typology were less likely to report having never made a suicide attempt. Creating typologies of suicidality may prove useful to clinicians seeking to better differentiate among suicidal patients within a limited period of assessment.
Despite the ubiquity of suicidality in behavioral health settings, empirically supported interventions for suicidality are surprisingly rare. Given the importance of resolving suicidality and therapists' anxieties about treating suicidal patients, there is a clear need for innovative services and clinical approaches. The purpose of the current study was an attempt to address some of these needs by examining the feasibility and use of a new intervention called the "Collaborative Assessment and Management of Suicidality" (CAMS) within a "Next-Day Appointment" (NDA) outpatient treatment setting. As part of a larger feasibility study, n = 32 suicidal patients were randomly assigned to CAMS care versus Enhanced Care as Usual (E-CAU) in an outpatient crisis intervention setting attached to a safety net hospital. Intent to treat suicidal patients were seen and assessed before, during, and after treatment (with follow-up assessments conducted at 2, 4, 6, and 12 months). The feasibility of using CAMS in the NDA setting was clear; both groups appeared to initially benefit from their respective treatments in terms of decreased suicidal ideation and overall symptom distress. Although patients rated both treatments favorably, the CAMS group had significantly higher satisfaction and better treatment retention than E-CAU. At 12 months post-treatment, CAMS patients showed significantly better and sustained reductions in suicidal ideation, overall symptom distress, and increased hope in comparison to E-CAU patients. CAMS was both feasible in this NDA setting and effective in treating suicidal ideation, distress, and hopelessness (particularly at 12 months followup).