Collaborative Assessment and

Management of Suicidality

Lithuania Conference

October 2016

Dr Eoin Galavan

The prevailing model/culture of addressing suicide in mental health care

What can be done differently Collaborative Assessment and Management of Suicidality

(CAMS) • Model and evidence for effectiveness

The story of establishing a suicide specific service Using CAMS in Community Mental Health Teams (CMHTs) CAMS case examples

Declaration of interest: CAMS-care consultant

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THERAPIST

PATIENT

Critique of Current Approach to Suicide Risk:

THE REDUCTIONISTIC MODEL

(Suicide = Symptom of Psychopathology)

DEPRESSION LACK OF SLEEP

POOR APPETITE

ANHEDONIA ...

? SUICIDALITY ?

Traditional treatment = inpatient hospitalization, treating the

psychiatric disorder, and using no suicide contracts…

The Collaborative Assessment and Management of

Suicidality (CAMS) identifies and targets Suicide as

the primary focus of assessment and intervention…

THERAPIST & PATIENT

PAIN STRESS AGITATION

HOPELESSNESS SELF-HATE

REASONS FOR LIVING

VS. REASONS FOR DYING

Mood

CAMS assessment uses the Suicide Status Form (SSF) as a means of

deconstructing the “functional” utility of suicidality; CAMS as an intervention

emphasizes a problem-focused intensive outpatient approach that is

suicide-specific and “co-authored” with the patient…

Suicidality

5

Psychotherapeutic

Philosophy

Negligence/Obligati

ons to client

Risk Management

and Treatment

Planning Strategies

Statics Risk Factor

Research

CAMS

“CAMS is an overall process of clinical

assessment, treatment planning, and

management of suicidal risk with suicidal

outpatients”

With 50-80 RCTS with suicidality as an outcome variable

There is mixed support for

medication-only approach

RCT’s and replications support:

• Dialectical Behavior Therapy (DBT)

• Cognitive Therapy for Suicide Prevention (CBT-SP)

• Collaborative Assessment and Management of Suicidality (CAMS)

• Non-demand follow-up contact (caring contacts)

Authors Sample/Setting n = Significant Results____ Jobes et al., 1997 College Students 106 Pre/Post Distress Univ. Counseling Ctr. Pre/Post Core SSF Jobes et al., 2005 Air Force Personnel 56 Between Group Suicide Outpatient Clinic Ideation, ED/PC Appts. Arkov et al., 2008 Danish Outpatients 27 Pre/Post Core SSF CMH Clinic Qualitative findings Jobes et al., 2009 College Students 55 Linear reductions Univ. Counseling Ctr. Distress/Ideation Nielsen et al., 2011 Danish Outpatients 42 Pre/Post Core SSF CMH Clinic Ellis et al., 2012 Psychiatric Inpatients 20 Pre/Post Core SSF Suicidal Ideation, depression, hopelessness Ellis et al., 2015 Psychiatric Inpatients 52 Suicide ideation/cognitions

_______________________________________________________________ Principal Setting & Design & Sample Status & Investigator Population Method Size Update_____ Comtois Harborview/Seattle CAMS vs. TAU 32 2011 published (Jobes) CMH patients “Next-day” appts. article Nordentoft Danish Center DBT vs. CAMS 108 2016 published (Aamund) CMH patients superiority trial article Jobes Ft. Stewart, GA CAMS vs. E-CAU 148 Final 12 mo. (Comtois) US Army Soldiers data collection Fosse Norwegian Centers CAMS vs. TAU 100 ITT underway CMH patients on-going Pistorello Univ. Nevada—Reno SMART Design 60 ITT recruited; (Jobes) CC Students TAU/CAMS/DBT post-assess Comtois Harborview/Seattle CAMS vs. TAU 200 IRB approved (Jobes) CMH patient Post-Inpatient D/C Training prep

From two diverse samples there were 636 written responses to SSF prompts (n = 152).

Collapsing data across constructs, 22% of responses pertain to Relational issues.

20% of written responses pertained to issues of Role Responsibility.

15% of responses related to issues of Self.

10% of responses related to Unpleasant Internal States.

Collapsing across constructs, 67% of responses were related to relational

issues, vocational challenges, self-related concerns, and internal emotional distress.

Suicide Assessment and Treatment Service, 2013

No suicidal people currently on clinical psychology wait lists

Referrals made at weekly MDT, or via email

Training, consultation and supervisory role for other CMHT staff

2 hours/week allocated to the SATS service

10-14 Clinical Psychologists (5 trainees) covering 7 CMHTS, mental health for older persons, mental health for intellectual disability, acute inpatient care

Management “by in” as a policy decision

Used by the team as the means by which the service addresses suicidality within the service user population

Systematic use: a coherent plan about how to utilise the resource within those people who are using the CAMS

Several users, with some arrangements/agreements about how to adapt, often implicit

Sole users

Does the CAMS ‘take more time’?

More time than what?

It takes time to do a thorough thoughtful

collaborative risk assessment, treatment

plan and stabilisation plan

Whose responsibility is it anyway?

Every mental health clinician has a

responsibility to be able to meet and manage

suicidality

Practical reality of leaving it to one discipline

is unworkable

Suicidal people equal threat and trouble

Unconscious effort to push it away or prove the risk is less than it really is “they are not really suicidal” or “they don’t really mean it” or

prove it is more than it really is to justify admission criteria “I’m very worried and it wouldn’t surprise me if they did it so I think we should admit”

Hate in the Countertransference: • they are not really sick, this is just behaviour, they are manipulative, they

are just looking for attention

I don’t want to work with them when they are suicidal, I want them in hospital until they are not suicidal, then I will work with them

Large, M. & Ryan, C. J. (2014). Disturbing findings about the risk of suicide and psychiatric hospitals (Editorial)

Hjorthoj, C.R., et al (2014). Risk of Suicide according to level of psychiatric treatment—a nationwide nested case control study. Found a strong dose effect relationship e.g. admitted patients had a 44.3 times the risk of suicide

Fear often drives admission

Admission may in the short term reduce risk for some, or at least it is perceived to do so (reduced access to lethal means, increased social contact inherent in an inpatient stay)

No admission is without risk (10-20% of deaths by suicide in UK adult mental health patient population occur in acute care)

However it may also be true that admissions increase risk and even cause suicide (shame, stigma, disappointment, mismatch of intervention/environment and problem type, reinforcing suicide as a means to solving problems)

“We believe it is likely that a proportion of people who suicide during or after an admission to hospital do so because of factors inherent in that hospitalisation” (Large & Ryan, 2014)

1. Issues of sufficient informed consent.

2. Issues of competent assessment of risk.

3. Need for empirically-oriented treatments.

4. Appropriate risk management (liability

issues).

What works wins!

Don’t negotiate to start doing something, there are a million creative reasons to tell you to stop

Do something, and allow people the option of telling you to stop…

Please stop delivering this thoughtful, comprehensive, evidenced based, collaborative, ethically minded, problem focused, well documented, risk assessment, risk management and suicide specific intervention

Heard

about

CAMS?

Id like to

start a

project

…what

do you

think?

Never heard

of it

No time

Not

possible

We’ve been

using a

model called

CAMS. Look

it works.

Here’s the

audit of

recent cases

You’ve been

seeing suicidal

people?

What

does

CAMS

mean?

Here’s

another

referral

Recommended model of training includes • 3 hour online training program, plus

• 1-1.5 days live role play training, plus

• Participation in approx 8 case consultation calls

• Full adherence/mastery usually takes 2-4 completed cases

• Decreases in anxiety about working with suicidal patients pre-post training, increases in confidence in assessing and treating suicidal behaviour. No differences across staff groups (Jobes, 2016)

• Rates of clinician behaviour change vary, approx 40% in our local audit, with a large study underway to explore this further (Jobes 2015)

• Post training consultation a major contributing factor to whether the model is used or not post training

Nscience 1 day training, London 22nd October, Ambassadors Bloomsbury Hotel, CAMS training

nscience.co.uk

Queries re CAMS training see CAMS-care.com or contact me on

camscare.galavan@gmail.com