Collaborative Assessment and Management of Suicidality

1. Introduction

Version followed: CAMS as described in Jobes, Managing Suicidal Risk: A Collaborative Approach, 3rd ed. (2023), using the Suicide Status Form-5 (SSF-5), as summarised by CAMS-care and Jobes's own recent papers (Tyndal, Zhang & Jobes 2021; Jobes, Chambers & Maclellan 2025). Where only the SSF-4 / 2nd ed. (2016) material is drawn on (the Therapeutic Worksheet, the Outcome form, the UCL competence map), this is flagged. The 3rd-edition book itself is not drawn on. [source: CAMS-care SSF page; Jobes et al. 2025; Tyndal et al. 2021]

What it is. CAMS (Collaborative Assessment and Management of Suicidality) is a suicide-specific therapeutic framework, not a new psychotherapy. Its authors call it "theoretically 'non-denominational' and integrative" (Jobes, Crumlish & Evans 2020). It gives a structure for assessing, stabilising, treating and tracking suicidal risk. Inside that structure the clinician uses whatever treatments they already practise (CBT, DBT skills, behavioural activation, insight-oriented work, couples work, medication referral) to treat the patient's own "drivers" of suicide. It runs alongside a patient's care until suicidality resolves, typically over 6–12 sessions, in any setting: outpatient, telehealth, inpatient, college counselling, community mental health. [source: Jobes 2012; Tyndal et al. 2021; Focus 2022]

How change is thought to happen. Suicide itself is the target, not just a symptom of a diagnosis. Suicidal thoughts and behaviour are understood as the patient's attempt to cope with intolerable pain and unmet needs. This rests on Shneidman's psychache/perturbation/press model, Beck's hopelessness theory and Baumeister's escape-from-self (self-hate) account. Change comes from four things. The clinician and patient build a shared understanding of the patient's "inner suicidal narrative" on the SSF, sitting side by side, with the patient treated as the expert. The patient is stabilised with a CAMS Stabilization Plan rather than reflexively hospitalised. The patient-defined drivers are then treated directly. The work finally turns to reasons for living, meaning and purpose. The aim is for suicide to stop being needed as a coping option. [source: Focus 2022; Jobes 2012; Tyndal et al. 2021; Carlat interview]

2. Framework

CAMS has three phases, each matched to a version of the SSF-5. [source: CAMS-care SSF page; Jobes et al. 2025]

Session count. There is no prescribed length (Jobes et al. 2025). Resolution often comes within 6–8 sessions and most patients resolve within 12 (Tyndal et al. 2021). The UCL competence map, drawing on the 2nd edition, describes negotiating an agreed trial period of about 3 months or 6–8 sessions. [source: Tyndal et al. 2021; Jobes et al. 2025; UCL competence map]

Criteria for moving from Phase 2 to Phase 3 (resolution). All three must hold for three consecutive sessions:

1. The patient rates overall suicide risk as very low: 1 or 2 out of 5. The SSF-4 outcome form words this as below 3.
2. The patient has managed suicidal thoughts and feelings effectively in the past week.
3. There has been no suicidal behaviour in the past week.

If any criterion is not met, tracking simply continues. [source: Jobes et al. 2025; SSF-4 Outcome form; Tyndal et al. 2021]

Version note: early trials required the absence of suicidal thoughts for three sessions. Jobes 2012 says suicidal coping is "essentially eliminated". Jobes now treats behavioural stability while managing suicidal thoughts and feelings as a successful outcome (Carlat interview). This guide follows the current, managed-thoughts criterion. [source: Jobes 2012; Carlat interview]

Other exits. Disposition can also be continued outpatient therapy focused on remaining drivers (under a new agreement), inpatient admission, referral, mutual termination, or the patient discontinuing on their own. These are recorded on the Outcome SSF. [source: SSF-4 Outcome form; UCL competence map]

Named variants (described by the authors; not detailed here): CAMS-4Teens with a Stabilization Support Plan for parents; inpatient CAMS (Menninger); CAMS group formats for veterans; CAMS Brief Intervention (CAMS-BI, proposed in 2012 as a one-session contact with nondemand follow-up); telehealth CAMS (see 4.17). [source: Jobes 2012; CAMS-care 3rd-edition webinar page]

3. Guiding principles

Jobes describes CAMS as resting on four pillars: empathy, collaboration, honesty and a suicide-focused approach (Jobes et al. 2025). The principles below expand on these from the sources.

• Empathy for the suicidal wish. Treat suicidality as understandable ("not necessarily rational") and as an attempt to meet real needs. Practically: validate the pain and the need before challenging suicide as the solution, and never blame or shame. [source: Tyndal et al. 2021; Carlat interview]
• Empathy is not endorsement. Practically: you can say you understand why suicide feels like an answer while clearly working toward other ways to meet the need. [source: Tyndal et al. 2021; UCL competence map]
• Collaboration: the patient is the expert and co-author. Practically: the patient writes, rates and ranks; you ask, clarify and record in their words; the treatment plan is "co-authored" and both of you sign it. [source: Focus 2022; Jobes, Crumlish & Evans 2020; Tyndal et al. 2021]
• Side by side, literally and figuratively. Practically: ask permission, then sit beside the patient with the SSF between you, so the form becomes a shared object rather than an interrogation. Jobes describes this as helping the patient regain a sense of control. [source: Focus 2022; Carlat interview; Jobes 2022 abstract]
• Honesty and transparency about limits. Practically: say plainly that the patient ultimately has control over whether they live. Say just as plainly that you have a legal and ethical duty to act if there is clear and imminent danger, and share your reasoning rather than acting covertly. [source: Tyndal et al. 2021; Carlat interview; UCL competence map]
• Suicide-focused, driver-oriented. Practically: suicide is Problem #1 every session. The other two problems are the patient-identified drivers, not a diagnosis-driven list. Treat the drivers directly. [source: Tyndal et al. 2021; Lynch, Colborn Bathe & Jobes 2022]
• Least restrictive care: outpatient first. Practically: use the Stabilization Plan to make outpatient care viable. Inpatient care should be "the last possible response versus the first response" (Jobes, Crumlish & Evans 2020), while still admitting when needed to save a life. [source: Jobes 2012; Tyndal et al. 2021]
• Framework, not a school of therapy. Practically: keep the CAMS structure (SSF every session, plan updated every session) and fill the middle of each session with interventions you are competent in, chosen to fit each driver. [source: Jobes, Crumlish & Evans 2020; Jobes 2012]
• Do-plans, not no-suicide contracts. Practically: the Stabilization Plan lists what the patient will do in a crisis, not a promise of what they will not do. [source: Tyndal et al. 2021]
• Structured and repeatedly measured. Practically: the Core Assessment is re-rated at the start of every session and drives decisions about resolution. [source: CAMS-care SSF page; Jobes et al. 2025]
• Documentation as care. Practically: the SSF is the progress note and medical record. Complete Section D and narrative notes every session; the SSF page says this also reduces malpractice liability. [source: CAMS-care SSF page; Tyndal et al. 2021]
• Alliance and motivation as mechanisms. Practically: notice and use the patient's ambivalence. Invite an earnest, time-limited trial of treatment rather than demanding commitment to live forever. [source: Jobes 2012; Carlat interview; UCL competence map]
• Hope through attainable goals. Practically: turn the "one thing" and the drivers into concrete, achievable goals, and end treatment by building reasons for living and a life with purpose. [source: Tyndal et al. 2021; Carlat interview]

4. Intervention inventory

The SSF is a licensed instrument. Its items are described here, not reproduced. Owners of the 3rd edition may photocopy it or use a web version; otherwise it is obtained through CAMS-care, and its use is intended for trained clinicians [source: CAMS-care SSF page; SSF-4 Outcome form footer]. Interventions 4.1–4.11 belong to the first session, 4.12–4.16 to interim sessions, 4.17 to the outcome session, and 4.18–4.19 are delivery adaptations.

4.1 Introducing CAMS and setting up side-by-side seating

• Purpose / when: At the start of the first session, once suicidal ideation has been disclosed or screened positive. The aim is to engage the patient as a collaborator from the first minute. The UCL map advises raising suicidal risk early in the session while engaging sensitively. [source: UCL competence map; Focus 2022]
• Steps:
  1. Name what you have heard: the patient is thinking about suicide, and you want to take that seriously and understand it from their point of view.
  2. Explain that you use a structured approach in which you both work on a form together. You will be asking for their own assessment of what is going on, because they are the expert on their own experience.
  3. Ask permission to move your chair beside theirs so you can both see the form. In telehealth, see 4.18.
  4. Hand the patient the first-session SSF and a pen.
  5. Be transparent early about confidentiality limits and about your duty to act if there is clear and imminent danger (see 4.11).
• Example language (illustrative): "What you've told me matters, and I'd like to understand it the way you experience it, not just tick boxes. There's a form I use that we fill in together. Would it be OK if I brought my chair round so we can both see it?"
• Watch for: Patients used to being assessed "at" often relax visibly once seated alongside. If a patient declines side-by-side seating, respect that and keep the form visible between you [synthesis]. Signs it is working: the patient begins correcting or adding to what is written. [source: Carlat interview; Focus 2022]

4.2 SSF Section A: Core Assessment ratings and qualitative prompts

• Purpose / when: First session, completed by the patient. It captures the patient's own view of the six constructs thought to drive suicide, and starts the shared narrative. It is repeated at the start of every later session. [source: Jobes et al. 2025; Jobes 2012]
• Steps:
  1. The patient rates five constructs on 1–5 scales: psychological pain, stress, agitation, hopelessness and self-hate. Each is followed by an incomplete-sentence prompt for the patient to finish in their own words (e.g. what they find most painful).
  2. The patient rates overall risk of suicide on a 1–5 scale from extremely low to extremely high.
  3. The patient ranks the first five constructs by importance. Overall risk is rated but not ranked.
  4. The patient rates how far their suicidality relates to thoughts and feelings about themselves versus about others.
  5. Stay alongside as the patient writes. Ask them to expand on each answer ("say more about that") and reflect back what you hear. Do not correct their ratings. [source: Focus 2022; Jobes et al. 2025; UCL competence map]
• Example language (illustrative): "You've put hopelessness at a 5 and ranked it first. Tell me what's most hopeless right now." / "You wrote that what hurts most is feeling like a failure to your kids. Can you help me understand that?"
• Watch for: Large gaps between the ratings and the narrative, such as low ratings alongside a detailed plan. Explore these gently rather than overriding the patient [synthesis]. The qualitative answers often name the drivers directly, so note them for 4.9. Jobes et al. (2025) say eliciting these responses validates the patient's experience and builds rapport. [source: Jobes et al. 2025]

4.3 Reasons for Living and Reasons for Dying

• Purpose / when: First session, Section A. It maps both sides of the patient's ambivalence in their own words and gives targets for treatment. [source: Focus 2022; Jobes et al. 2025]
• Steps:
  1. The patient lists up to five reasons for living and up to five reasons for dying.
  2. The patient ranks each list by importance.
  3. Explore the reasons for dying with the same curiosity as the reasons for living. The reasons for dying often point to drivers.
  4. Do not push for reasons for living if few come. Jobes says exploring them too early can feel invalidating; return to them once the alliance is established (see 4.16). [source: Carlat interview]
• Example language (illustrative): "Let's put both sides down: what keeps you here, and what pulls you toward dying. Both columns are real, and I want to understand both."
• Watch for: A token reason for living ("my dog, I guess") offered to reassure you. Jobes treats this as a possible empathic failure: step back and ask what might give life purpose and meaning. An empty reasons-for-living column is clinically important; record it and weigh it in the risk judgment. [source: Carlat interview] [synthesis for the second point]

4.4 Wish to live / wish to die ratings

• Purpose / when: First session, Section A. It quantifies ambivalence. [source: Jobes et al. 2025]
• Steps:
  1. The patient rates their wish to live and their wish to die on two 0–8 (nine-point) scales.
  2. The difference gives a Suicide Index Score, which sorts patients into three types: mostly wish to live, ambivalent, or mostly wish to die.
  3. Reflect the balance back and use it to set the tone of treatment planning. [source: Jobes et al. 2025]
• Example language (illustrative): "So part of you is at a 6 for wanting to live and part of you is at a 5 for wanting to die. That tug-of-war is exactly what we can work with."
• Watch for: A predominant wish to die calls for closer attention to imminence and means (4.10–4.11). [synthesis] [uncertain: the exact scoring formula and any cut-points are in the 3rd-edition book]

4.5 The "One Thing" response

• Purpose / when: First session, the last item of Section A. It focuses the patient on the single change that would most reduce suicidality, which often reveals the main driver. The patient completes a sentence about the "one thing that would help me no longer feel suicidal" (Focus 2022, quoting Jobes 2016). [source: Focus 2022; Jobes et al. 2025]
• Steps:
  1. The patient completes the prompt in writing.
  2. Explore the answer. If it is not achievable (e.g. a lost person returning), look for the need underneath it.
  3. Translate it into realistic, achievable goals in the treatment plan. Jobes describes writing the answer down and turning it into goals. [source: Carlat interview]
• Example language (illustrative): "You wrote 'my wife coming back.' I can't promise that. What would her coming back give you that you're missing so badly right now?"
• Watch for: Answers such as "nothing" or "dying". Treat these as information about hopelessness, not as refusal. [synthesis]

4.6 SSF Section B: collaborative assessment of risk factors and warning signs

• Purpose / when: First session, guided by the clinician after Section A. It covers the empirically based risk variables in a non-judgemental, shared way and identifies the suicide plan, access to means and further drivers. [source: Tyndal et al. 2021; UCL competence map]
• Steps: Work through each variable with the patient, recording their answers in their words. The 2nd edition, as mapped by UCL, lists these variables:
  • suicidal ideation: frequency and duration
  • suicide plan, preparation and rehearsal, including access to means
  • history of suicidal behaviour (single or multiple attempts)
  • impulsivity, as the patient sees it
  • substance use
  • significant loss
  • relationship problems
  • perceived burdensomeness
  • health problems or physical pain
  • sleep problems
  • legal or financial problems
  • shame
  Tyndal et al. (2021) count about fifteen variables in the current form. [source: UCL competence map; Tyndal et al. 2021] [uncertain: the exact SSF-5 item list]
• Example language (illustrative): "Now I'd like to go through some things we know from research can raise risk. Some will apply, some won't. When you think about suicide, how often does it come, and how long does it stay?"
• Watch for: Plans, preparation and rehearsal, and any access to lethal means, all feed directly into the Stabilization Plan (4.10). Variables endorsed here (e.g. insomnia, drinking) often become indirect drivers. [source: Tyndal et al. 2021; CAMS Therapeutic Worksheet]

4.7 Exploring the suicidal wish and offering a trial of treatment

• Purpose / when: First session, during treatment planning, especially with ambivalent or strongly suicidal patients. It builds motivation for treatment without denying the patient's autonomy. [source: UCL competence map; Carlat interview]
• Steps:
  1. Acknowledge honestly that the patient has the option of ending their life. Jobes, as reported in the Carlat interview, frames this as "Of course you can kill yourself."
  2. Ask whether ending their life is really necessary to get the underlying needs met. Reported wording: "Do you have to end your life to get your needs met?"
  3. Propose a defined trial: a mutually agreed period during which the patient sets the suicide option aside and earnestly tries treatment. UCL describes about 3 months or 6–8 sessions; Jobes describes "six or 10 sessions". UCL frames agreeing to this as a critical condition of treatment.
  4. Note that suicide remains available later. This lowers the stakes of agreeing now. [source: Carlat interview; UCL competence map] [uncertain: the quoted phrases are as reported in an interview summary, not taken from the manual]
• Example language (illustrative): "I'm not going to pretend I can stop you. What I'm asking is whether we can put suicide on the shelf for the next couple of months and give this a real try. If it doesn't help, that option isn't going anywhere."
• Watch for: Don't let this slide into a no-suicide contract. The agreement is to engage in treatment, alongside a do-plan, not a promise not to die. [source: Tyndal et al. 2021]

4.8 Section C: co-authoring the CAMS Treatment Plan

• Purpose / when: End of the first session; updated at the end of every interim session. It turns the assessment into an agreed, suicide-specific plan. [source: Tyndal et al. 2021; CAMS-care SSF page]
• Steps:
  1. Problem #1 is always self-harm potential. Its intervention is the Stabilization Plan (4.10). Record that the plan was completed and its intended duration.
  2. Problems #2 and #3 are the two patient-identified drivers (see 4.9). A CAMS plan has no more than three problems.
  3. For each problem, write a goal and observable objectives, the interventions (type and frequency) and an expected duration, in language the patient agrees with.
  4. The patient confirms understanding and agreement.
  5. The clinician records the judgment about imminent danger (4.11).
  6. Both sign. Give the patient a copy. [source: Tyndal et al. 2021; UCL competence map; Jobes 2022 abstract] [uncertain: exact field layout of the SSF-5 plan]
• Example language (illustrative): "Of everything we've written, which two things most make you want to die? Those are what we'll work on. How would you like to word them?"
• Watch for: Drivers worded as diagnoses ("MDD") rather than in the patient's terms ("my mother", "I hate myself"). Keep the patient's language. Signs it is working: the patient owns the plan and refers back to it. [source: Lynch et al. 2022] [synthesis for the first point]

4.9 Identifying direct and indirect drivers

• Purpose / when: First session, feeding Problems #2–3, and refined across interim sessions. Drivers are the issues that compel the patient to consider suicide, and they are the core targets of CAMS. [source: Lynch et al. 2022; CAMS Therapeutic Worksheet]
• Steps:
  1. Pull candidate drivers from the Section A rankings, the qualitative answers, the reasons for dying, the "one thing" and the Section B variables.
  2. Distinguish the two kinds:
     • Direct drivers are the immediate triggers of suicidal states: specific thoughts, feelings, behaviours, and recurring relational or self-concept themes.
     • Indirect drivers are background vulnerabilities, such as homelessness, depression, substance use, PTSD, isolation or insomnia.
  3. Ask the patient to choose the two most important.
  4. Common categories in CAMS samples are relational (about a quarter), unpleasant internal states, role responsibilities and self/internal descriptors. Use these to prompt exploration, not to impose a driver. [source: CAMS Therapeutic Worksheet (2nd ed.); UCL competence map; Lynch et al. 2022]
• Example language (illustrative): "When the urge to die is strongest, what has usually just happened? And what's in the background making you more vulnerable, like sleep, drinking or being alone?"
• Watch for: Drivers too global to treat ("life"). Narrow them to something workable. [synthesis]

4.10 The CAMS Stabilization Plan (CSP)

• Purpose / when: First session, still seated side by side. It is reviewed every interim session. It is the key intervention that makes outpatient care viable. Jobes describes it as more than an acute crisis tool because it sits inside driver-focused treatment. It is a "cousin" of the Stanley–Brown Safety Plan and the Crisis Response Plan. [source: Tyndal et al. 2021]
• Steps (four components):
  1. Reduce access to lethal means. Open with a frank, empathic discussion. Remove what can be removed: stockpiled medication, firearms, ligatures, knives. Reduce what cannot be removed, such as access to heights or rail lines. A trusted person may secure means, with the patient's consent and with you verifying it was done. This is lethal-means counselling: focus on storage and removal, not method detail.
  2. Coping strategies and crisis numbers. Build a list of about five coping steps to redirect, delay, distract or self-soothe. Order them as a hierarchy, for example self-soothing, distracting, absorbing or pleasurable activities, then using social contacts. If the crisis persists after these, the patient contacts a crisis line or emergency services; list the local numbers (in the US, 988).
  3. Relational support. Name people the patient can contact (family, friends, mentors, clergy), and plan to reduce isolation. Optionally make a Crisis Support Plan with a spouse or friend, or invite a supporter to a session.
  4. Barriers to treatment. Identify what could stop attendance, such as transport, childcare, cost or medical issues. Plan remedies: local agencies, bus passes, sliding-scale fees, coordination with other providers.
  5. Tick the CSP as completed on the Treatment Plan, with its duration.
  6. Give the patient a copy or let them photograph it on their phone. Jobes notes that people in crisis may not remember the plan, so it needs to be to hand. [source: Tyndal et al. 2021; Carlat interview; UCL competence map]
• Example language (illustrative): "You mentioned the tablets you've been saving. While we work on this, who could hold them for you, and how would we know it's done?" / "When it gets really dark, what's the first thing that's helped even a little before?"
• Watch for: Generic coping items the patient doesn't believe in. Tyndal et al. call coping-skill selection "a bit of an art", because the plan is for specific dark moments. Help with "I don't know what helps" by trying skills in session. Signs it is working: the patient can say where the plan is and reports using steps between sessions. [source: Tyndal et al. 2021; UCL competence map]

4.11 Imminent-danger judgment, honesty about hospitalisation, signing and Section D

• Purpose / when: End of the first session; re-judged every session. It decides whether outpatient care is safe and creates the record. [source: Tyndal et al. 2021; CAMS-care SSF page]
• Steps:
  1. Judge whether a satisfactory plan exists for a crisis between sessions. If not, and the danger is clear and imminent, arrange a higher level of care. Explain this openly and try to get on the same side as the patient. Hospitalisation is the last response, not the first.
  2. Both sign the SSF. Give the patient copies.
  3. Complete Section D after the session: mental status exam, provisional DSM/ICD diagnosis, overall risk judgment and a narrative case note. [source: Tyndal et al. 2021; Carlat interview; Jobes et al. 2025]
• Example language (illustrative): "I want to be straight with you: if I believed you were about to act, the law says I have to act to keep you safe, and I'd tell you exactly what I was doing and why. Right now, with this plan, I think we can keep working together as an outpatient. Do you agree?"
• Watch for: Patients hiding risk out of fear of admission. Being transparent early reduces this. [source: Carlat interview] [synthesis for the inference]

4.12 Interim (tracking) session structure

• Purpose / when: Every session after the first, until resolution. It keeps suicide in focus while most of the time goes on treating drivers. [source: CAMS-care SSF page; Tyndal et al. 2021]
• Steps:
  1. Open: the patient completes the interim SSF Core Assessment (the six ratings) plus the past-week items: suicidal thoughts or feelings, whether they were managed, and any suicidal behaviour.
  2. Check the CSP: ask what was used, what helped, what didn't, and whether it was used at all. Revise it.
  3. Middle (most of the session): treat Problems #2–3 with chosen interventions (4.14), and use the Therapeutic Worksheet where useful (4.13).
  4. Close: side by side, revisit the Treatment Plan. Confirm Problems #2–3 are still the right drivers and update goals, interventions and duration.
  5. Re-judge imminent danger and complete the record.
  6. Track progress toward the three-session resolution criteria (Section 2). [source: CAMS-care SSF page; Tyndal et al. 2021; SSF-4 Outcome form; Jobes, Crumlish & Evans 2020]
• Example language (illustrative): "Let's start with the ratings, the same ones as last time. You've gone from a 4 to a 2 on agitation. What changed?"
• Watch for: Rising ratings or new behaviour. Return to stabilisation (4.10–4.11) before driver work. Signs it is working: falling ratings, CSP steps being used, and the patient bringing driver material themselves. [synthesis]

4.13 CAMS Therapeutic Worksheet

• Purpose / when: Interim sessions, when the clinician and patient need a deeper shared formulation of the patient's suicidality and drivers. It was revised in the 3rd edition; the version used here is from the 2nd edition (2016). [source: CAMS Therapeutic Worksheet; CAMS-care 3rd-edition webinar page]
• Steps (2nd-ed. structure):
  1. Personal story of suicidality. The patient describes why they feel suicidal, how they relate to suicide, and their history with it.
  2. Drivers. Re-list Problems #2 and #3. Sort the material into direct drivers (thoughts, feelings, behaviours, relational and self themes) and indirect drivers (background vulnerabilities).
  3. Suicidal conceptualisation: "suicide as an option." For each driver, identify the bridges that move the patient toward suicidal action and the barriers that hold them back.
  4. Complete only the sections that fit the patient. Add to the worksheet across sessions. [source: CAMS Therapeutic Worksheet] [uncertain: 3rd-edition revisions]
• Example language (illustrative): "Let's map how you get from 'my boss criticised me' to 'I should kill myself.' What are the steps in between, and what has stopped you before?"
• Watch for: Use the identified barriers to strengthen the CSP. Use the bridges as targets for driver treatment. [synthesis]

4.14 Driver-specific treatment

• Purpose / when: The core of the interim sessions. It treats the reasons the patient wants to die, using interventions matched to each driver. [source: Tyndal et al. 2021; Jobes et al. 2025]
• Steps:
  1. For each driver, choose an evidence-based intervention you are competent in, or refer for one.
  2. Write it into the plan and review it at the end of each session.
  3. Examples given by the authors:
     • self-hatred: CBT or insight-oriented therapy
     • trauma or combat PTSD: exposure-based or trauma-focused therapy
     • lack of purpose: values clarification
     • employment problems: vocational counselling
     • depression: behavioural activation or medication referral
     • relational conflict: couples therapy
     • pain: pain management
     • emotion dysregulation: DBT skills or mindfulness [source: Jobes et al. 2025; Tyndal et al. 2021; Lynch et al. 2022; Jobes 2022 abstract; CAMS-care SSF page]
• Example language (illustrative): "Feeling worthless is the driver you ranked first. One approach I use is to catch those self-attacking thoughts and test them. Want to try that this week?"
• Watch for: Exposure-based trauma work for a suicidal patient needs specific consent and safety steps. Get informed consent describing the temporary rise in distress. Keep the CSP active and reviewed every session. Consider delaying exposure while the patient is in acute crisis or has recent suicidal behaviour, and pace it. [synthesis] Referral is acceptable within CAMS, but keep CAMS tracking going with the referred treatment coordinated [synthesis].

4.15 Engaging supporters: Crisis Support Plan and Stabilization Support Plan

• Purpose / when: When family or friends can reduce isolation or help secure means. This is routine with adolescents in CAMS-4Teens. [source: Tyndal et al. 2021; Carlat interview; CAMS-care 3rd-edition webinar page]
• Steps:
  1. With consent, identify a supporter.
  2. Agree what they will do in a crisis (a Crisis Support Plan).
  3. Invite them to a session if useful.
  4. With teens, use the Stabilization Support Plan to guide parents.
  5. Discuss early on, with the family, what treatment can and cannot guarantee. [source: Tyndal et al. 2021; Carlat interview] [uncertain: Stabilization Support Plan contents]
• Example language (illustrative): "Would it help if your sister came in for part of a session, so she knows what to do and what not to do if things get bad?"
• Watch for: Supporters who respond with control or anger. Coach them in their role. [synthesis]

4.16 Reasons for living, meaning and post-suicidal life

• Purpose / when: Later interim sessions, once the alliance is established and the patient is stabilising. Early sessions build survival skills; later ones shift to reasons for living and meaning. Near the end, the focus is on a meaningful, purposeful life. [source: Carlat interview; UCL competence map]
• Steps:
  1. Return to the first-session Reasons for Living list and expand it.
  2. Ask what would give purpose and meaning.
  3. Link this to values-based goals.
  4. The 3rd edition adds exploration of "post-suicidal life" and an optional Living Status Form (LSF). [source: Carlat interview; CAMS-care 3rd-edition webinar page] [uncertain: LSF content and procedure]
• Example language (illustrative): "Now that suicide isn't taking up so much room, what do you want your life to be about?"
• Watch for: Premature focus on positives before the drivers have eased. This can feel invalidating. [source: Carlat interview]

4.17 Outcome/Disposition session

• Purpose / when: When the third consecutive session meets the resolution criteria. It consolidates learning and agrees next steps. [source: SSF-4 Outcome form; CAMS-care SSF page]
• Steps:
  1. The patient completes the Core Assessment and the past-week items.
  2. Confirm that the resolution criteria have been met for the third consecutive session. If not, continue tracking.
  3. The patient writes what was most helpful in treatment, and what they learned that could help if suicidal feelings return.
  4. Agree the disposition (continued therapy, referral, mutual termination, etc.) and record any next appointment.
  5. Both sign.
  6. Offer occasional booster sessions if ending by mutual agreement. [source: SSF-4 Outcome form; UCL competence map]
• Example language (illustrative): "Three sessions in a row your risk has been a 1 or 2 and you've handled the hard moments. Let's write down what got you here, so it's there if you ever need it again."
• Watch for: Ambivalence about ending. Some patients fear losing the relationship. Discuss continuing on a new, non-suicide-focused contract. [source: UCL competence map]

4.18 Telehealth CAMS

• Purpose / when: Remote delivery. Jobes is comfortable with fully telehealth CAMS. [source: Jobes, Crumlish & Evans 2020; Carlat interview; Jobes 2022 abstract]
• Steps:
  1. In informed consent, cover emergency procedures and the duty to protect. Know the patient's location, and ideally have a third-party contact (spouse, friend, parent).
  2. Either both of you hold a blank SSF and complete it in parallel, with the patient dictating and both checking the clinician's copy, or the clinician screen-shares a fillable digital SSF and enters the patient's answers.
  3. The clinician's copy is the record. The patient keeps theirs for crises.
  4. Means reduction can be done live on video. Jobes describes a patient removing a medication stash during a session. [source: Jobes, Crumlish & Evans 2020; Jobes 2022 abstract; Carlat interview]
• Example language (illustrative): "Before we start, can you confirm where you are right now, and who I could call if we got cut off and I was worried?"
• Watch for: Dropped connections during high-risk moments. Agree a reconnection plan in advance. [synthesis]

4.19 Documentation and adherence

• Purpose / when: Every session. [source: CAMS-care SSF page; Jobes 2012]
• Steps:
  1. Use the SSF as the progress note.
  2. Add a narrative note each session.
  3. In supervision, use the CAMS Rating Scale (Comtois et al. 2011) to check fidelity: SSF each session, side-by-side work, plan updated, CSP reviewed. [source: Jobes 2012; Tyndal et al. 2021] [uncertain: CAMS Rating Scale items; the parenthetical list is synthesis]
• Watch for: Drift into using CAMS as a one-off assessment form without tracking. [synthesis]

5. Handling problems

The sources say little about troubleshooting. Each item below is tagged as sourced or as [synthesis].

• Token or absent reasons for living. Treat a token reason as a possible empathic failure: step back to the pain, then ask what would give purpose and meaning. Delay detailed reasons-for-living work until the alliance is stronger. [source: Carlat interview]
• Strong ambivalence or reluctance to commit. Name the ambivalence and use the wish-to-live/wish-to-die ratings. Acknowledge the patient's autonomy. Propose a time-limited, earnest trial of six to ten sessions, with suicide "on the shelf". Use motivational techniques that build on any intention to live. [source: Carlat interview; UCL competence map]
• Stuck: ratings not improving after several sessions. Re-examine whether Problems #2–3 are the real drivers. Use the Therapeutic Worksheet to remap bridges and barriers. Check whether the chosen intervention fits the driver, or whether referral (trauma therapy, medication, substance-use care) is needed. Treatment can continue past 12 sessions; there is no fixed endpoint. [source: Tyndal et al. 2021 for revising drivers and the plan; Jobes et al. 2025 for no fixed length] [synthesis for the sequence]
• Fear of hospitalisation and concealing risk. Be transparent from session 1 about when and why you would have to act. Share your reasoning. Treat inpatient care as the last resort and the CSP as the alternative. [source: Carlat interview; Tyndal et al. 2021]
• CSP not used (non-adherence). Ask gently and persistently where the plan is and what got in the way of using it. Revise coping items the patient doesn't believe in. Rehearse steps in session. Put the plan on the patient's phone. [source: Tyndal et al. 2021; Carlat interview] [synthesis for rehearsal]
• Missed sessions or dropout risk. Address barriers to attendance in the CSP from session 1: transport, childcare, cost, medical issues. Coordinate with other providers. Dropout is a recorded disposition on the Outcome SSF. Outreach after a missed session is good practice [synthesis]. [source: Tyndal et al. 2021; SSF-4 Outcome form]
• Overwhelm during the first session. Pace Section A by pausing after the ratings with the highest numbers. Validate before moving on. Complete the CSP before the session ends even if parts of Section B are carried forward to the next session. Overwhelm in later sessions should trigger a return to stabilisation before driver work. [synthesis] [uncertain: whether the 3rd edition allows splitting the first session]
• Acute crisis mid-treatment (e.g. psychotic decompensation, new attempt). Patients can use the CSP, attend the session and get urgent medication review via a consulting psychiatrist; CAMS can then continue. After any suicidal behaviour the three-session resolution count restarts, because the criteria require none in the past week. [source: Tyndal et al. 2021 case of "Eve"; SSF-4 Outcome form] [synthesis for the restart rule]
• Imminent danger. If no satisfactory between-session plan can be made and the danger is clear and imminent, arrange inpatient or intensive home treatment. Explain your reasoning and keep the patient informed. Involve family early where you can. After discharge, resume CAMS tracking, because post-discharge risk is elevated. [source: Tyndal et al. 2021; UCL competence map; Carlat interview] [synthesis for resuming CAMS]
• Ruptures, e.g. the patient feels controlled or unheard. Jobes reports that patients have described conventional safety planning as controlling. Repair by returning to the side-by-side stance: put the pen and the wording back in the patient's hands and re-rank the drivers together. Use rupture-repair skills from your own model. [source: Carlat interview] [synthesis for the repair steps]
• Drivers that can't be changed, such as bereavement or chronic illness. Shift the goal from removing the driver to changing the patient's relationship with it: acceptance, meaning-making, pain management, social support. Use the "one thing" exploration to find the need underneath. [synthesis; pain management named by Tyndal et al. 2021]
• Patient wants to stop CAMS before resolution. Respect the choice. Complete the Outcome SSF with a disposition of the patient discontinuing on their own, update the CSP, and offer an open door. [source: SSF-4 Outcome form] [synthesis for the remaining steps]
• Chronic suicidality or repeated self-harm (e.g. BPD). CAMS was not superior to DBT on any outcome in a BPD trial. For chronic, multi-problem self-harm, consider DBT as the primary treatment or a referral to it. [source: Focus 2022] [synthesis for the recommendation]
• Clinician anxiety and liability fears. Keep the SSF and narrative notes complete every session. The SSF page says this reduces malpractice liability. Get consultation and supervision with CAMS-trained colleagues. [source: CAMS-care SSF page; Tyndal et al. 2021] [synthesis for consultation]
• Adolescents. Use CAMS-4Teens and the Stabilization Support Plan with parents. CAMS-care reports that teens at the Hope Institute stabilise in about 5 weeks on average. [source: CAMS-care SSF page; CAMS-care 3rd-edition webinar page] [uncertain: detailed teen procedures]

Sources

Sources

• Focus (APA), 2022: review article covering CAMS (doi 10.1176/appi.focus.20220083)
• Tyndal, Zhang & Jobes (2021). The CAMS stabilization plan for working with patients with suicide risk. Psychotherapy
• Jobes (2012). CAMS: An evolving evidence-based clinical approach to suicidal risk. SLTB 42(6)
• CAMS-care: Innovations in clinical suicide prevention, CAMS update and the 3rd edition of Managing Suicidal Risk
• Lynch, Colborn Bathe & Jobes (2022). Suicidal drivers within CAMS treatment planning. Archives of Suicide Research
• CAMS Therapeutic Worksheet (from Jobes 2016, 2nd ed.)
• SSF-4 Outcome/Disposition Final Session form
• Jobes (2022). CAMS lecture abstract, 13th Triple i conference, Koper
• Jobes, Crumlish & Evans (2020). The COVID-19 pandemic and treating suicidal risk: The telepsychotherapy use of CAMS. J Psychotherapy Integration (accepted manuscript)
• Jobes, Chambers & Maclellan (2025). A patient-centered approach for assessing suicidal risk. Psychiatric Annals 55(12)
• The Carlat Report: Suicide assessment and treatment, interview with David A. Jobes
• CAMS-care: The Suicide Status Form
• UCL CORE: CAMS competence map (self-harm adult framework)

Further reading (not drawn on)

• Jobes, D. A. (2006). Managing Suicidal Risk: A Collaborative Approach. Guilford Press.
• Jobes, D. A. (2016). Managing Suicidal Risk: A Collaborative Approach (2nd ed.). Guilford Press.
• Jobes, D. A. (2023). Managing Suicidal Risk: A Collaborative Approach (3rd ed.). Guilford Press. This is the version followed, through the secondary summaries above; the book is not drawn on.
• Comtois, K. A., et al. (2011). CAMS Rating Scale (adherence), cited in Jobes 2012.
• Swift, J. K., et al. (2021). Meta-analysis of CAMS, SLTB (key source; evidence only, not used for procedures).