reducing short term suicide risk after hospitalization...

CAMS 6/5/18

Kate Comtois, U of WA. [email protected] 1

Kate Comtois, PhD, MPHProfessor, Dept of Psychiatry and Behavioral SciencesHarborview Medical CenterUniversity of Washington

Reducing Short Term Suicide Risk after Hospitalization (CAMS)

• The experience of suicidality and what drives and maintains it.

• Engaging a suicidal individual collaboratively.• Suicide Status Form and how to use it to assess and

manage suicide risk and guide the initial session.• CAMS crisis response planning.• Planning ongoing or follow-up treatment.

Overview

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Follow-up

TreatmentManagement

Risk FormulationAssessmentScreening

Overview of Clinical Interventions for Suicide Risk

CAMS is a framework for collaborative assessment, management and

treatment of suicide risk.

Suicidal

The Experience of Suicidality What are the drivers of suicide?

Guess I need to deal with it.

Time to check out.

Non-suicidal

Life stress

Why?Drivers

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There are many stressors, including psychiatric diagnosis, experienced by suicidal and non-suicidal individuals alike.

“Indirect drivers” of suicidality

Depression

Relationship problems

Financial problems

Homelessness

Four theories on suicide: Direct DriversWhy do people die by suicide?

1. Interpersonal Theory of Suicide (Joiner, 2005)

2. Dialectical Behavioral Therapy (DBT) Model of Emotions (Linehan, 1993)

3. Cubic Model of Suicide (Shneidman, 1987)

4. Cognitive Model of Suicidal Behavior (Wenzel & Beck, 2008)

A shift from epidemiological assessment (risk factors) to theory driven assessment (underlying psychology).

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Interpersonal Theory of Suicide (Joiner, 2005)Desire for death + Capability for suicide

Serious Attempt or Death by Suicide

Perceived Burdensomeness

ThwartedBelongingness

Acquired Capability

Those who desire death: Frustrated psychological needs

Those who are capable of lethal self-injury

Hopelessness

DBT Model of Emotions (Linehan, 1993)Emotion dysregulation + Impulsive behavior

Impulsive behavior:An urgent desire to escape

from an overwhelming emotional distress.

Emotion Dysregulation

The DBT Model of Emotions states that a person’s behavior corresponds with their

experienced level of emotional upset.

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Shneidman's Cubic Model of Suicide (1987)

Pain, Press and Perturbation

Suicide

Perturbation

Press

Pain

Shneidman. (1987). A psychological approach to suicide. Cataclysms, crises and catastrophes.

Suicide is the only escape

from this pain.

Wenzel & Beck's Cognitive Model of Suicidal BehaviorHopelessness, Selective Attention, Attentional Fixation

Hopelessness and cognitive constriction.

Wenzel & Beck (2008) A cognitive model of

suicidal behavior

It’s never going to

get better.

HopelessnessEverything in my life is

wrong.

Selective attention

Attentional fixation

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Four theories on suicide should be consideredPeople die by suicide because…

Interpersonal Theory of Suicide…they become hopeless about belonging with others and feeling

worthwhile and gain the capability to inflict lethal self-injury.

DBT Model of Emotions …they are overwhelmed by painful emotions and engage in

impulsive action to end the pain.

Cubic Model of Suicide …they experience unbearable emotional pain, overwhelming

stress and an agitated urge to end the pain.

Cognitive Model of Suicidal Behavior…they become hopeless, focus on negative aspects of their lives

and fixate on suicide as the only escape.

Management vs. Treatment

Nothing is working. I should just kill myself.

What do you think about a short hospitalization?Client Therapist

Nothing is working. I should just kill myself.

Can we take a closer at that way of thinking? Client Therapist

1

2

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Therapist engages in interventions that seek to reduce risk by modifying risk factors related to suicide. Management is optimally, but not

necessarily, collaborative.

Management

Therapist SuicideClient

ConnectednessDepression treatmentLethal means safety

Safety planning

Management of Suicide Risk

Therapist and client engage in a collaborative relationship to resolve risk by targeting internal factors that are unique/intrinsic to suicide risk.

Treatment is necessarily collaborative.

Treatment

Therapist SuicideClient

Treatment of Suicide Risk

Direct drivers

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Over time, the patient grows in confidence and responsibility in self-management of suicide risk.

Ellis. (2004). Collaboration and a self-help orientation in therapy with suicidal clients.

Treatment to Promote Self-Management

Therapist

SuicideClient

Treatment of Suicide RiskConsultative & Collaborative

Self-Management

Common elements of suicide treatments:• Clear treatment framework.• Agreed-upon strategy to manage suicidal crises.• Active therapist: Overt, determined and

persistently connecting and collaborative stance. • Direct treatment of suicidality (regardless of

diagnosis) as the priority in care.• Exploratory interventions: In-depth analysis of

suicidality.• Attention to non-adherence.

Adapted from Weinberg et al., 2010 in J Clin Psych

Psychotherapy for Suicidality

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Narrative Interviewing

Please tell me the storyof what led to the

suicidal crisis. Just let me listen to you.

Narrative interviewing: An effort find a story so that actions make sense. “Tell” and “story”

correlated with alliance (Michel et al., 2004).

Self-esteemSeparation and Loss

RejectionRestrained or Dependent

Aeschigroup

Narrative Interviewing Themes

Psychotherapy for Suicidality

Collaboration Goal Target

Management Optimal when collaborative

Reduce risk

External factors related to

suicide risk

Treatment Necessarilycollaborative

Resolve risk

Internal factorsintrinsic to suicide risk

Management Treatment

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C Collaborative

A Assessment and

M Management of

S Suicidality

(CAMS)

An alternative…

CAMS is a suicide-specific therapeutic framework emphasizing five core

components of collaborative clinical care.

Component I: Assessment of Suicidal Risk – the SSF

Component II: Treatment Planning

Component III: Deconstruction of Suicidogenic Problems

Component IV: Problem-Focused Interventions

Component V: Development of Reasons for Living

Overview to CAMS Assessment and Care

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Collaborative Assessment and Management of Suicidality

Creating Collaboration

???? ??

THERAPIST

CLIENT

DEPRESSIONLACK OF SLEEP

POOR APPETITE

ANHEDONIA ...

? SUICIDALITY ?

Traditional treatment = inpatient hospitalization, treating

the psychiatric disorder, and using no suicide contracts…

Attitudes and Approach:

Creating Collaboration

Suicide is a

symptom

Standard clinical interactions, including suicide interventions,

are clinician-as-expert interviewing the client.

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Shame

Clinician-as-expert does not create collaboration

Attitudes and Approach:Creating Collaboration

Therapist Client

Interrogation

Checklist

Fear of hospitalization

COLLABORATIVELY ASSESSING RISK: Targeting suicide as the focus of treatment

THERAPIST & CLIENT

SUICIDALITY

PAIN STRESS AGITATION

HOPELESSNESS SELF-HATE

REASONS FOR LIVING VS. REASONS FOR DYING

Mood

CAMS Treatment = Weekly outpatient care that is suicide-

specific, emphasizing the development of other means of coping

and problem-solving, thereby systematically eliminating the

need for suicidal coping.

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Separate the client from

suicide

Join with the client

Conceptualize suicidality together

SSF

Direct drivers


This means…

• Want to directly demonstrate to client that you empathize with their suicidal wish:– You have everything to gain and almost nothing to lose by

trying this potentially life saving treatment.– You can always kill yourself later.

• At the same time, clarify when you would have to take action that they might not choose – know your limits:– If they won’t work collaboratively on treatment plan.

OR– If they say they can’t control their impulses.

OR…

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Maybe time to break up? Just for a few months?

I know it’s hard. You can always get back together.

We’ve been together so long…

Commitment strategies

Ambivalence

Therapist ClientSuicide

Here’s a pen. I’m going to ask you to do some ratings about

how you feel right now.

CAMS SSF: Section A

Suicide.SSFWould you mind if I sat next to you?

SSF

SSF

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First understand the experience of

suicidality.

This measure is only used during

the index session.

CAMS SSF Section A

Psychological PainStressAgitationHopelessnessSelf-hateOverall Risk of Suicide

Reasons for Living and Dying

One Thing

Yourself vs. Others

Wish to Live vs. Wish to Die

Section BSuicide PlanSuicide PreparationHistory of SuicidalityCurrent IntentImpulsivitySubstance AbuseSignificant LossInterpersonal Isolation

Section C

CAMS SSF: Review important suicide risk factors

After understanding the experience of suicidality in Section A, ask for the SSF and complete Section B.

Epidemiological Assessment

Can I take this back for us to go through the other side?

SSF

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CAMS is a suicide-specific therapeutic framework emphasizing five core

components of collaborative clinical care.


Component II: Treatment Planning & Crisis Response Plan




Component II: Treatment PlanningThe Crisis Response Plan

CAMS SSF: Toward the end of session, develop a

treatment plan that targets key drivers of suicidality.

Section C

Problem

#

Problem

Description

Goals and

ObjectivesInterventions Sessions

1Self-harm

potential

Outpatient

safety

Crisis

Response Plan

2

3

YES _ NO _ Pt understands and commits to OP treatment plan?

YES _ NO _ Clear and imminent danger of suicide?

Patient signature Clinician signature

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Component II: Treatment PlanningThe Crisis Response Plan

Section B

Epidemiological risk factors for suicide.

Crisis Response Plan

Problem 2

Problem 3

Section C

The Crisis Response Planmanages immediate risk

by facilitating means safety, crisis planning,

increasing social support and ensuring treatment

attendance.

Management of Suicide Risk

CAMS Crisis Response Planning:An Orientation and Philosophy of Care

1. Means safety2. Crisis planning3. Decreasing isolation4. Treatment attendance

Crisis Response Plan

Suicidal

Psychotherapy

Life worth living

Dark moment

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A central treatment goal within CAMS is to establish a viable outpatient treatment plan that can keep the patient out of the hospital.“I am a therapist, and I am required to take steps to save your life if it comes to that. I have to keep hospitalization as an option. That being said, hospitalization is number 101 on the list of things to do. I have 100 other things we can do to make sure you stay out of the hospital.”


1. Reduce or eliminate access to lethal means.

CAMS Crisis Response PlanningMeans Safety

• Counseling on access to lethal means

• Educating family members• Receipt from 3rd party• Gun locks• Prescribed medications• Environmental precautions

Ways to reduce access to lethal means:

1. ______________2. ______________3. ______________

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2. Develop and use a Crisis Coping Card

CAMS Crisis Response PlanningCrisis Coping Card

• Distraction activities• Criteria for appropriate activities• Emergency contact

Crisis Coping Card

Crisis Card

The value of delay, distract, and redirect…


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2. Develop and use a Crisis Coping Card

CAMS Crisis Response PlanningCrisis Coping Card

Sample Crisis Coping Card1. Take a walk.2. Call Donny: 206-555-12343. Watch a movie from DVD collection.4. Try to sleep.5. Get out of the house – mall, park, anywhere.6. Call or text Kate: 206-123-45677. Emergency contact: 800-273-8255

Construct a suicide prevention tool box—a “hope kit” or “distress tolerance box” – either physical…

CAMS Crisis Response PlanningHope Kit

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Or virtual…

CAMS Crisis Response PlanningVirtual Hope Box

Virtual Hope Box: Clinician’s Guide and User’s Guidehttp://t2health.dcoe.mil/apps/virtual-hope-box

3. Create interpersonal supports

Other important strategies to consider:• Get a release to reach out to the supports

yourself if concerned or patient disappears.• Schedule sessions with family or friends.• Give homework to talk about important

issues with family or friends.

CAMS Crisis Response PlanningCreate Interpersonal Supports

People I can call for help or to decrease my isolation:1. _______________________________________2. _______________________________________

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4. Attend treatment reliably as scheduled over the next one to three months (or length of stay).

CAMS Crisis Response PlanningTreatment Attendance

Attending treatment as scheduled:Potential Barrier: Solutions I will try:

1. _________________________________________2. _________________________________________

Specific Direct Drivers of Suicide Risk (and other

therapeutic issues)

CAMS SSF: In addition to the Crisis Response Plan, it is critical to provide hope and direction for future

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Four theories on suicide should be consideredPeople die by suicide because…

Interpersonal Theory of Suicide…they become hopeless about belonging with others and feeling

worthwhile and gain the capability to inflict lethal self-injury.

DBT Model of Emotions …they are overwhelmed by painful emotions and engage in

impulsive action to end the pain.

Cubic Model of Suicide …they experience unbearable emotional pain, overwhelming

stress and an agitated urge to end the pain.

Cognitive Model of Suicidal Behavior…they become hopeless, focus on negative aspects of their lives

and fixate on suicide as the only escape.

After Session, Final Paperwork

Mental Status Exam

AlertnessMoodAffectThought continuity

Diagnostic Impression

Final SSF Page:Clinical Observations

and Conclusions

Provides structure for excellent

documentation

Overall Suicide Risk

Case Notes

Next Appointment

Signature

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Component II: Treatment Planning




Overview to CAMS Assessment and Care

In CAMS we use the key SSF ratings

Ongoing sessions with suicidal clients: Start with re-assessment of suicide evaluation.

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CAMS Focuses on Resolution of suicidality:Treat Direct Drivers Using Your Own Approach

Interpersonal Theory of SuicideThwarted belongingness Connection and belonging

Perceived burdensomeness Value, purpose and self-worthHopelessness, helplessness Hope, agency

Cognitive Theory of SuicideSelective attention, attn. fixation Mindfulness and perspective

Emotion DysregulationEmotion dysregulation and skillsdeficits in emotion-regulation,

problem-solving, communication

Mindfulness, distress tolerance, emotion regulation, interpersonal

effectiveness, problem-solving

Suicidal Non-suicidalA B

Crisis planning is check in and

confirmation or update

Update treatment plan focused on suicide drivers discussedas of that session

CAMS Ongoing Treatment Planning: Evaluate Progress and Plan Next Steps

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Again After Session:Complete SSF

Clinical Observations and Conclusions

Continuing excellent documentation

Mental Status Exam

AlertnessMoodAffectThought continuity

Diagnostic Impression

Overall Suicide Risk

Case Notes

Next Appointment

Signature

TherapistClient

• Frame of treatment• Agreed-upon goals• Agreed-upon tasks• Positive emotional bonds• Target non-adherence

• Suicide conceptualization• Agreed-upon crisis plan• Suicide-focus independent

of diagnosis• Suicide risk prioritized• Suicide risk management• Treatment of primary

drivers to resolve risk

Collaborative relationship

Clinical focus on suicide

Summary of CAMS Therapeutic Framework

reducing short term suicide risk after hospitalization...

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