Collaborative Assessment and Management of Suicidality

1. Collaborative Assessment and
Management of Suicidality
Lithuania Conference
October 2016
Dr Eoin Galavan

2.  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

3. ??
??
??
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…

4. 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. 5
Psychotherapeutic
Philosophy
Negligence/Obligati
ons to client
Risk Management
and Treatment
Planning Strategies
Statics Risk Factor
Research
CAMS

6. “CAMS is an overall process of clinical
assessment, treatment planning, and
management of suicidal risk with suicidal
outpatients”

9.  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)

11. 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

12. _______________________________________________________________
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

13.  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.

14. 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

15. 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

17. 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

18. 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

19.  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

20.  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)

22. 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).

23.  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

24. Heard
about
CAMS?
Id like to
start a
project
…what
do you
think?
Never heard
of it
No time
Not
possible

25. 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

26.  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

27. 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