Collaborative Assessment & Management of Suicidality Theresa Sharpe, PhD University Counseling Center TAMU-CC

Challenges of Working with Suicidal Clients Stressful for therapist Limited hospitalization options Limitations of outpatient therapy Medication limitations (difficulty of getting psychiatry appt, medication compliance) Concerns about litigation if client completes suicide Stressful for therapist, worry about patient safety Crisis mgt can be challenging when insurance/schedule limits session frequency. Most of us aren’t able to do intensive outpatient (e.g, daily therapy) even with suicidal clients Solo practitioners may have limited after hours crisis counseling options Suicidal blackmail” = therapist’s fear that client may complete suicide if therapist doesn’t do everything possible to accommodate client

Most suicidal people… Don’t actually want to end their life, rather they want an end to their psychological suffering and pain Tell others (including therapists) that they are thinking about suicide as an option for coping with their pain Have psychological problems, interpersonal problems, and poor coping skills (which therapists are well trained to address) Are searching for a solution and need help to find an alternative to suicide

CAMS as a Clinical Philosophy Suicide focused therapeutic framework Theoretically “non-denominational” Can be used in a variety of treatment settings Therapist conveys empathy for suicidal client – no shame or blame Goal is to address and manage suicidality on an outpatient basis & keep client out of the hospital if they are willing to engage & commit to collaborative treatment plan. Clinicians use their own clinical skills, clinical judgement, and treatment approaches

CAMS Approach Client is quickly engaged in the clinical assessment of their suicidal risk and in the management of their own outpatient safety and stability. CAMS provides both structure and a process for therapist and client to navigate over “some rocky (suicidal) roads. Emphasis on therapeutic alliance Therapist is honest & transparent about professional & legal obligation to hospitalize the client if they pose a clear & imminent risk of danger to themselves

CAMS Benefits Enhances client motivation & active engagement in treatment Helps client find alternative ways of coping with assistance of therapist Client learns to rely on therapist but also learns to rely on self as they learn better ways to cope and solve problems.

CAMS is a proven clinical intervention that reliably and effectively treats patient-defined suicidal drivers leading to rapid reductions in suicidal ideation, overall symptom distress, depression, and hopelessness. In addition, there are promising data for decreasing suicide attempts and self-harm behaviors. https://cams-care.com/about-cams/evidence-base

The Joint Commission issued a Sentinel Event Alert on February 24, 2016 titled “Detecting and Treating Suicidal Ideation in all Settings.” In recommendations for Behavioral Health Treatment and Discharge, CAMS was identified as one of three “evidence-based clinical approaches that help to reduce suicidal thoughts and behaviors.” Joint commission is an independent, not for profit group in the US that administers voluntary accreditation programs for hospitals and other healthcare organizations. The commission develops performance standards that address crucial elements of operation such as patient care.

Three Phases of CAMS Phase 1. Initial Assessment & Treatment Planning Phase 2. Clinical Tracking Phase 3. Clinical Outcomes

Suicide Status Forms Used to conduct & document a multi-dimensional collaborative assessment of the suicidal client’s initial suicidal risk Collaboratively develop & document a suicide specific treatment plan Clinically track & document ongoing suicidal risk as well as note updates to treatment plan Determine and document clinical outcomes when CAMS is concluded

Screening for Suicidality Jobes recommends using symptom based screening form prior to each session so therapist is alerted to suicide risk potential

Introducing CAMS to the Client Need to focus on suicide risk within the first 5-10 minutes of session Transitioning to topic of suicide risk Introducing the SSF Ask permission to sit next to client Use with any currently identified suicidal client (anyone who is currently suicidal or has been in the past week) Transitioning to topic of suicide risk (p. 58) Introducing the SSF (p.59)

SSF-4 Initial Form – Section A Client completes Part A and then ranks items in importance Client rates their overall risk of suicide Clients indicates degree to which suicidality is related to thoughts/feelings about self versus others Under reasons for living and dying - client encouraged to fill out as many spaces as possible but not required to fill every space Client lists the one thing that would help them no longer feel suicidal

Section B Therapist takes back the clipboard and completes this section still sitting beside the client Therapist is calm, nonjudgemental

Section C – Treatment Plan Problem # 1 = self-harm potential Goals & objectives = safety & stabilization Intervention = stabilization plan Client is coauthor of treatment plan

Negotiating the Treatment Plan Be clear about limits of confidentiality and that imminent danger to self will necessitate hospitalization Therapist communicates empathy for client’s suicidal wish but asks is suicide the best way to cope? Therapist emphasizes that plan will focus on increasing client’s psychological pain tolerance, creating healthier ways to cope with emotional pain, working to make client’s life worth living

Time Limited Treatment Plan Per Jobes, it’s not reasonable for a highly suicidal client to give up suicide as an option for coping indefinitely. CAMS averts the power struggle over whether client can take his/her life with an alternative proposition ‘Let’s see if together we can find a viable alternative to suicide to better deal with your pain and suffering.” Client is asked to commit to a mutually negotiated suicide specific treatment plan for a specified period of time (usually 3 months). Jobes insists that while client is engaged in the treatment, (s)he must be fully committed (along with the therapist) to that treatment.

Stabilization Plan: Step 1 Step 1: Reducing access to lethal means Therapist needs to empathetically acknowledge client’s attachment to lethal means while also challenging client to substitute an alternative source of comfort Client willingness to remove or decrease access to lethal means is positive If they aren’t willing to engage in lethal means reduction – outpatient therapy may not be viable & hospitalization may be needed Remove lethal means from client’s direct access or environment (e.g, gun needs to be transferred to friend or dismantled), pills must be removed. 3rd party can leave VM for therapist verifying that means have been removed. Reduce access to locations (avoid bridge, have partner keep car keys)

Step 2: List coping strategies “Let’s come up with five things that you can do when you are in crisis…” Have client list these. Examples: walk; listen to music, take a bath, play with pet, watch a movie, journal, take a nap, read, call supportive friend, artwork or craft Therapist adds #6 – crisis counseling number Communicates the message to client that “you can learn to cope when you are in crisis” List can be transferred to back of therapist business card “your commitment to me and to your treatment is that you will do each item on this card if you are in a crisis state – feeling impulsive, really upset, or suicidal. The goal is for you to help yourself cope more effectively when you are feeling upset or overwhelmed. If you do each of the 5 items on this list and they don’t work or you are still feeling bad –you can call the crisis number. Another option would also be to repeat the items on the list. Remember no coping strategy will work every time but you have several to choose from and there’s a good chance that by doing one or more items on the list that you’ll feel at least a little better…” First 5 items are focused on client using internal resources to manage a crisis before turning to external resource (therapist) Emphasizes the importance of client learning to develop a thicker psychological skin to manage the ups and downs of life

Step 3: List relational supports Friends, family, clergy, co-workers who can play a supportive role Decrease isolation Strengthen connection with relational supports

Step 4: Explore potential barriers to counseling attendance Be proactive in identifying potential barriers & ways to manage these Discussion of what will happen if client doesn’t keep next counseling appointment

Treatment Plan #2 & #3 Problems #2 & #3 = drivers of suicide “What are the two problems that we need to fix for you to be no longer suicidal?” OR “ what are the 2 things that put your life in peril?” Therapist helps client to identify goals & objectives and suggests interventions

Section C (continued) Commitment to treatment – “Patient understands and agrees to treatment plan?” - Yes “Patient is at imminent danger of suicide (hospitalization indicated)” - No Client & therapist sign treatment plan Give client a copy or have them take a picture of treatment plan with phone

Section D Therapist completes this section after session Mental Status exam, Diagnosis, therapist rating of patients overall risk level, case notes SSF-4 serves as record of session Initial CAMS session is challenging to finish in 50 minutes, may need to extend session Consultation is important

Suicide Tracking Form- Section A Complete Section A of form within the first 10-15 min of session. Client rating of items is quick (less than five minutes) Probe to understand what is contributing to ratings of each item

Section A Client indicates if they have experienced suicidal thoughts or feeling in past week Client indicates if they managed suicidal thoughts/feelings. Therapist asks about use of the stabilization plan. Client indicates if they engaged in suicidal behavior. Remainder of session focuses on suicidal drivers

Section B – Treatment Plan Update Review & update treatment during last 10 minutes of session #2 & #3 may change. During CAMS treatment, we “sharpen” drivers and get more to the root of what makes client suicidal Client & therapist sign treatment plan Give client a copy or have them take a picture of treatment plan with phone

Section C – Therapist Postsession Evaluation

Therapeutic Worksheet Can be used during 2nd session or any time during course of CAMS treatment Further exploration of client’s personal story of suicide, drivers of suicide (#2 and #3 from treatment plan) including direct and indirect drivers & bridges and barriers to “going to next level”

Suicide Tracking Outcome Form Administer during 3rd consecutive session of resolved suicidality (overall risk of suicide is 1 or 2, no suicidal behavior and effectively managed suicidal thoughts/feelings) Clients identifies helpful aspects of treatment plan & what they learned that could be helpful if they were suicidal in the future. Can be completed by therapist for different outcome dispositions

Demonstration – Initial CAMS Session

Role Play

Demonstration CAMS Interim Session

Role Play

CAMS Therapeutic Worksheet

CAMS Resources & Training https://cams-care.com/ Online 3 hour video training presented by Dr. David Jobes

CAMS Discussion Questions