Reducing Short Term Suicide Risk after Hospitalization (CAMS) Kate - - PowerPoint PPT Presentation

Kate Comtois, PhD, MPH

Professor, Dept of Psychiatry and Behavioral Sciences Harborview Medical Center University 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

Follow-up Treatment Management Risk Formulation Assessment Screening

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

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 Drivers

Why do people die by suicide?

• 1. Interpersonal Theory of Suicide (Joiner, 2005)
• 2. Dialectical Behavioral Therapy (DBT) Model
• f 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).

Interpersonal Theory of Suicide (Joiner, 2005)

Desire for death + Capability for suicide Serious Attempt or Death by Suicide Perceived Burdensomeness Thwarted Belongingness Acquired Capability

Those who desire death: Frustrated psychological needs Those who are capable

• f 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.

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

• nly escape

from this pain.

Wenzel & Beck's Cognitive Model of Suicidal Behavior

Hopelessness, Selective Attention, Attentional Fixation

Hopelessness and cognitive constriction.

Wenzel & Beck (2008) A cognitive model of suicidal behavior

It’s never going to get better. Hopelessness Everything in my life is wrong. Selective attention Attentional fixation

Four theories on suicide should be considered

People 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

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 Suicide Client Connectedness Depression treatment Lethal 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 Suicide Client

Treatment of Suicide Risk

Direct drivers

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 Suicide Client

Treatment of Suicide Risk

Consultative & 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

Narrative Interviewing

Please tell me the story

• f 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-esteem Separation and Loss Rejection Restrained or Dependent Aeschi group

Narrative Interviewing Themes

Psychotherapy for Suicidality

Collaboration Goal Target Management Optimal when collaborative Reduce risk External factors related to suicide risk Treatment Necessarily collaborative Resolve risk Internal factors intrinsic to suicide risk

Management Treatment

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

Collaborative Assessment and Management of Suicidality Creating Collaboration

?? ?? ??

THERAPIST CLIENT

DEPRESSION

LACK 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.

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.

Separate the client from suicide Join with the client Conceptualize suicidality together

SSF

Direct drivers

Attitudes and Approach: Creating Collaboration

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…

Attitudes and Approach: Creating Collaboration

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 Client Suicide

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.

SSF

Would you mind if I sat next to you?

SSF SSF

First understand the experience of suicidality. This measure is

• nly used during

the index session.

CAMS SSF

Section A

Psychological Pain Stress Agitation Hopelessness Self-hate Overall Risk of Suicide Reasons for Living and Dying One Thing Yourself vs. Others Wish to Live vs. Wish to Die

Section B

Suicide Plan Suicide Preparation History of Suicidality Current Intent Impulsivity Substance Abuse Significant Loss Interpersonal 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

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 & Crisis Response Plan Component III: Deconstruction of Suicidogenic Problems Component IV: Problem-Focused Interventions Component V: Development of Reasons for Living

Component II: Treatment Planning The 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 Objectives Interventions Sessions 1 Self-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

Component II: Treatment Planning The Crisis Response Plan

Section B

Epidemiological risk factors for suicide. Crisis Response Plan Problem 2 Problem 3

Section C

The Crisis Response Plan manages 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 safety
• 2. Crisis planning
• 3. Decreasing isolation
• 4. Treatment attendance

Crisis Response Plan

Suicidal Psychotherapy Life worth living

Dark moment

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.”

CAMS Crisis Response Planning: An Orientation and Philosophy of Care

• 1. Reduce or eliminate

access to lethal means.

CAMS Crisis Response Planning Means 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. ______________

• 2. Develop and use a

Crisis Coping Card

CAMS Crisis Response Planning Crisis Coping Card

• Distraction activities
• Criteria for appropriate activities
• Emergency contact

Crisis Coping Card

Crisis Card

The value of delay, distract, and redirect…

CAMS Crisis Response Planning: An Orientation and Philosophy of Care

• 2. Develop and use a Crisis Coping Card

CAMS Crisis Response Planning Crisis Coping Card

Sample Crisis Coping Card

• 1. Take a walk.
• 2. Call Donny: 206-555-1234
• 3. Watch a movie from DVD collection.
• 4. Try to sleep.
• 5. Get out of the house – mall, park, anywhere.
• 6. Call or text Kate: 206-123-4567
• 7. Emergency contact: 800-273-8255

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

CAMS Crisis Response Planning Hope Kit

Or virtual… CAMS Crisis Response Planning Virtual Hope Box

Virtual Hope Box: Clinician’s Guide and User’s Guide http://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 Planning Create Interpersonal Supports

People I can call for help or to decrease my isolation:

• 1. _______________________________________
• 2. _______________________________________

• 4. Attend treatment reliably as

scheduled over the next one to three months (or length of stay).

CAMS Crisis Response Planning Treatment Attendance

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

• 1. _________________________________________
• 2. _________________________________________

Section C (Clinician):

OUTPATIENT TREATMENT PLAN (Refer to Sections A & B)

Problem # Problem Description Goals and Objectives Evidence for Attainment Interventions (Type and Frequency) Estimated # Sessions 1 Self-Harm Potential Outpatient Safety

Crisis Response Plan:

2 3 YES ____ NO _____ Patient understands and commits to outpatient treatment plan? YES ____ NO _____ Clear and imminent danger of suicide?

____________________________________ _____________________________________

Patient Signature Date Clinician Signature Date

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

Four theories on suicide should be considered

People 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 Alertness Mood Affect Thought continuity Diagnostic Impression

Final SSF Page: Clinical Observations and Conclusions Provides structure for excellent documentation

Overall Suicide Risk Case Notes Next Appointment Signature

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

Section A (Patient): I have thoughts of ending my life: 0 1 2 3 4

(0=Never; 1=Rarely; 2=Sometimes; 3=Frequently; 4=Always)

Rate each item according to how you feel right now. 1) RATE PSYCHOLOGICAL PAIN (hurt, anguish, or misery in your mind, not stress, not physical pain): Low pain: 1 2 3 4 5 :High pain 2) RATE STRESS (your general feeling of being pressured or overwhelmed): Low stress: 1 2 3 4 5 :High stress 3) RATE AGITATION (emotional urgency; feeling that you need to take action; not irritation; not annoyance): Low agitation: 1 2 3 4 5 :High agitation 4) RATE HOPELESSNESS (your expectation that things will not get better no matter what you do): Low hopelessness: 1 2 3 4 5 :High hopelessness 5) RATE SELF-HATE (your general feeling of disliking yourself; having no self-esteem; having no self-respect): Low self-hate: 1 2 3 4 5 :High self-hate 6) RATE OVERALL RISK OF SUICIDE: Extremely low risk: 1 2 3 4 5 :Extremely high risk (will not kill self) (will kill self)

In CAMS we use the key SSF ratings

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

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

Interpersonal Theory of Suicide Thwarted belongingness Connection and belonging Perceived burdensomeness Value, purpose and self-worth Hopelessness, helplessness Hope, agency Cognitive Theory of Suicide Selective attention, attn. fixation Mindfulness and perspective Emotion Dysregulation Emotion dysregulation and skills deficits in emotion-regulation, problem-solving, communication Mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, problem-solving

Suicidal Non-suicidal

A B

TREATMENT PLAN UPDATE Problem # Problem Description Goals and Objectives Evidence for Attainment Interventions (Type and Frequency) Estimated # Sessions 1 Self-Harm Potential Outpatient Safety

Crisis Response Plan:

2 3 _____________________________________ _____________________________________ Patient Signature Date Clinician Signature Date

Section B (Clinician): Y __ N __ Suicidal Thoughts? Y __ N __ Suicidal Feelings? Y __ N __ Suicidal Behaviors? "I have thoughts . . .” # of sessions at “0” or “1” o 1st sess o 2nd sess o 3rd sess **Complete Suicide Tracking Outcome Form after 3rd consecutive session at "0" or "1" Patient Status:

• Discontinued treatment o No show o Referral to: _______________
• Hospitalization
• Cancelled o Other: ___________________

Crisis planning is check in and confirmation or update Update treatment plan focused on suicide drivers discussed as of that session

CAMS Ongoing Treatment Planning: Evaluate Progress and Plan Next Steps

Again After Session: Complete SSF Clinical Observations and Conclusions Continuing excellent documentation

Mental Status Exam Alertness Mood Affect Thought continuity Diagnostic Impression Overall Suicide Risk Case Notes Next Appointment Signature

Therapist Client

• Frame of treatment
• Agreed-upon goals
• Agreed-upon tasks
• Positive emotional bonds
• Target non-adherence
• Suicide conceptualization
• Agreed-upon crisis plan
• Suicide-focus independent
• f diagnosis
• Suicide risk prioritized
• Suicide risk management
• Treatment of primary

drivers to resolve risk

Collaborative relationship Clinical focus

• n suicide

Summary of CAMS Therapeutic Framework