Suicidality (CAMS) Framework: Grounding in Philosophy and Reaching - - PowerPoint PPT Presentation

The Collaborative Assessment and Management of Suicidality (CAMS) Framework: Grounding in Philosophy and Reaching Towards Future Developments

Kevin J. Crowley, Ph.D.

CAMS-care Senior Consultant CAMS-care, LLC

Today the field of suicidology is exploding…

 Suicide research is increasing exponentially  VA and DOD are spending multi-millions on suicide prevention  State legislation requiring suicide-specific training for mental

health professionals continuing education (e.g., Washington)

 The potential impact of the lived-experience and attempt

survivor movement

 An increasing emphasis on evidence-based treatments  National Action Alliance (Clinical Care Task Force  “Zero

Suicide” movement to raise the standard of clinical care) at a systems level.

But there is still a professional crisis…

Clinical Work with Suicidal Patients: Ethical Issues and Professional Challenges (PPRP: Jobes, Rudd, Overholser, & Joiner, 2008)

1.

Issues of sufficient informed consent about suicide risk.

2.

Issues of competent and thorough assessment of suicide risk.

3.

Little use of evidence-based clinical interventions and treatments for suicide risk.

4.

Issues with risk management and paralyzing concerns about malpractice liability.

A Significant Policy Development

CAMS MI PACT TMBI Safety Planning CRP + RFL Means Restriction can be used through out

Safety Planning, Means Restriction Counseling

DBT, CT-SP

The Collaborative Assessment and Management of Suicidality (CAMS)

The First SSF—CUA Counseling Center 1987

First session of CAMS—SSF Assessment, Stabilization Planning, Driver-Specific Treatment Planning, and HIPAA Documentation CAMS Interim Tracking Sessions CAMS Outcome/Disposition Session

At Its Core, What is CAMS?

CAMS is a therapeutic framework for applying the SSF. It’s used until suicidal risk resolves. Adherence requires thorough suicide assessment and problem-focused interventions that target and treat patient-defined suicidal “drivers.”

CAMS Philosophy



Empathy for suicidal states—no shame, no blame



Collaboration with suicidal patient in all aspects of the intervention



Honesty and transparency throughout clinical care

CAMS as Therapeutic Framework



Focus on Suicide—from beginning to middle to end



Outpatient Oriented—goal is to keep a suicidal patient in outpatient care



Flexible and “Nondenominational”—across theories and techniques

The CAMS Philosophy: Approaching Suicide

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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…

Traditional Clinician as Expert Engagement

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

Suicidality

The CAMS approach: Building a strong alliance and increasing patient motivation

What is DRIVING this person’s suicide risk?

(Jobes et al., 2011; Tucker et al., 2015)  Indirect Drivers: Factors that make this person feel like s/he

is in a state of “dis-ease” or “dis-order”

• Examples include: negative life events, psychosocial stressors,

psychiatric illnesses

• These may be profoundly painful, but they do not necessarily

trigger acute crises.

 Direct Drivers: The way this person thinks/feels about

indirect drivers that sets suicide up as an option.

• Suicidal ideation and behaviors are functional. They are possible

solutions for pain.

• By definition, direct drivers must be idiosyncratic.

Indirect Driver(s)* Suicide as an Option *Some examples of indirect drivers that inserted above include:

Depression PTSD Symptoms Relationship Problems Chronic Medical Issues Marital Conflict Substance Abuse Bad Grades Unemployment Homelessness Financial Difficulties Pending Deployment Incarceration

?

Indirect Driver Suicide as an Option Direct drivers bridge the gap. They explain how this person gets from indirect drivers to considering/choosing suicide as an option.

“A lot of people struggle with X, but not everyone who does wants to kill themselves. How are you seeing X that makes you feel like suicide is an option or the only option for dealing with it?”

Direct Driver(s)*

CAMS Therapeutic Worksheet

CAMS: “Driver”-Oriented Treatment

 The patient’s self-defined

problems are the basis for a “driver”-oriented treatment plan

 Over the course of CAMS we try

to “sharpen” the drivers and get more “direct.”

 Targeting and treating suicidal

drivers can help make suicidal coping obsolete

The Suicide Status Form (SSF): Putting Philosophy into Practice

First session of CAMS—SSF Assessment, Stabilization Planning, Driver-Specific Treatment Planning, and HIPAA Documentation CAMS Interim Tracking Sessions CAMS Outcome/Disposition Session

SSF Core Assessment

Electronic SSF

(in progress!!!)

What does the evidence say?

Psychometrics of the Core SSF (Jobes et al., 1997; Conrad et al., 2009)

Correlational and Open Clinical Trial Support for SSF/CAMS

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 and cognitions Ellis et al., 2017 Inpatients (& post-discharge) 104 SI, cognitions, depression, hopelessness, funct. impare, well-being, psych flexibility

Randomized Controlled Trials of CAMS

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________

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 Andreasson Danish Centers DBT vs. CAMS 108 2016 published (Nordentoft) CMH patients superiority trial article Jobes

• Ft. Stewart, GA

CAMS vs. E-CAU 1482017 published article Pistorello

• Univ. Nevada (Reno) SMART Design 62 Manuscript (Jobes)

College Students TAU/CAMS/DBT in preparation Ryberg Norwegian Centers CAMS vs. TAU 100 Manuscript in (Fosse) preparation Comtois Harborview/Seattle CAMS vs. TAU 200 Intent to treat (Jobes) Suicide attempters Post-Hosp. D/C underway Depp et al San Diego VAMC CAMS vs. Outreach 176 Grant awarded Walk in Veterans Same Day Services _______________________________________________________________________________ _________

CAMS Next-Day-Appointment RCT

CAMS RCT (Comtois et al., 2011)

Operation Worth Living (OWL)

Control Group E-CAU 3 months of

• utpatient care (n=75)

Experimental Group CAMS 3 months of

• utpatient care (n=73)

Dependent Variables: Suicidal Ideation/Attempts, Symptom Distress, Resiliency, Primary Care visits, Emergency Department Visits, and Hospitalizations. Measures: SSI, OQ-45, SASI-Count, CDRISC, PCL-M, SF-36, NSI, THI…(at 1, 3, 6, 12 months)

Consenting Suicidal Soldiers (n=148)

Outcome CAMS E-CAU Any suicidal ideation (SSI) 6.63 5.38 Any suicide-related episode 1.47 1.30 Any behavioral health-related episode 1.15 1.27 Any suicide-related wellness check/escort 1.29 1.23 Any behavioral health-related wellness check/escort 1.05 1.11 Any suicide-related ER visit 2.03 1.39 Any behavioral health-related ER visit 1.62 1.15 Any suicide-related IPU admission 1.90 1.02 Any behavioral health-related IPU admission 1.59 1.08 Any suicide attempt/hospitalization 2.07 1.56 Symptom distress (OQ-45) 5.58 4.96 PTSD symptoms (PCL-M) 3.48 3.07

• Note. “Post-intervention”

assessed at 3 months.

Pre-Post Effect Sizes

Per Cohen (1988) small effect = 0.2 medium effect = 0.5 large effect = 0.8

CAMS had large effects But so did E-CAU…

Treatment Outcome Results (n=148)

Significant 3 month finding for CAMS eliminating suicidal ideation No significant between-group differences

• n suicide attempts (only 9 in the study)

How is CAMS being applied across the systemic levels discussed?

CAMS

New Developments on the Horizon

NIMH-Funded R-34; PI: Jacque Pistorello, Ph.D.; Co-I: David Jobes, Ph.D.

Stage 1 Stage 2

CAMS-Relational Agent System

“Dr. Dave”

NIMH-funded SBIR Phase I: Linda Dimeff, David Jobes, & Kelly Koerner

CAMS-RAS Report

CAMS for Kids

CAMS for Kids (Cont.)

The evolution of CAMS

3rd Edition

Assessment Treatment Outcomes