Reducing Short Term Suicide Risk after Hospitalization (CAMS) Kate Comtois, PhD, MPH Professor, Dept of Psychiatry and Behavioral Sciences Harborview Medical Center University of Washington
Overview • 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 of Clinical Interventions for Suicide Risk Screening Assessment Risk Formulation Management Treatment Follow-up CAMS is a framework for collaborative assessment, management and treatment of suicide risk.
The Experience of Suicidality What are the drivers of suicide? Guess I need to deal with it. Non-suicidal Life stress Time to check out. Suicidal Why? Drivers
There are many stressors, including psychiatric diagnosis, experienced by suicidal and non-suicidal individuals alike. “Indirect drivers” of Financial suicidality problems Depression Relationship 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 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).
Interpersonal Theory of Suicide (Joiner, 2005) Desire for death + Capability for suicide Those who desire death: Frustrated psychological needs Those who are capable Thwarted of lethal self-injury Belongingness Acquired Hopelessness Capability Perceived Burdensomeness Serious Attempt or Death by Suicide
DBT Model of Emotions (Linehan, 1993) Emotion dysregulation + Impulsive behavior Emotion Dysregulation Impulsive behavior: An urgent desire to escape from an overwhelming emotional distress. 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) Press Pain, Press and Perturbation Perturbation Suicide Pain Shneidman. (1987). A psychological approach to suicide. Cataclysms, crises and catastrophes.
Wenzel & Beck's Cognitive Model of Suicidal Behavior Hopelessness, Selective Attention, Attentional Fixation Selective Hopelessness It’s never Everything attention going to in my life is get better. wrong. Hopelessness and cognitive constriction. Attentional Suicide is the fixation Wenzel & Beck (2008) only escape A cognitive model of from this pain. suicidal behavior
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 1 Therapist Client short hospitalization? Nothing is working. I should just kill myself. Can we take a closer at 2 Client Therapist that way of thinking?
Management of Suicide Risk Connectedness Depression treatment Lethal means safety Safety planning Client Therapist Suicide Management Therapist engages in interventions that seek to reduce risk by modifying risk factors related to suicide. Management is optimally , but not necessarily , collaborative.
Treatment of Suicide Risk Direct drivers Therapist Suicide Client Treatment 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 of Suicide Risk Consultative & Collaborative Suicide Client Self-Management Therapist Treatment to Promote Self-Management 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.
Psychotherapy for Suicidality 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
Narrative Interviewing Narrative Themes Interviewing Self-esteem Please tell me the story Separation and Loss of what led to the Rejection suicidal crisis. Just let Restrained or Dependent me listen to you. Aeschi group Narrative interviewing: An effort find a story so that actions make sense. “ Tell ” and “ story ” correlated with alliance (Michel et al., 2004).
Psychotherapy for Suicidality Treatment Management Collaboration Goal Target External factors Optimal when Reduce Management related to collaborative risk suicide risk Internal factors Necessarily Resolve Treatment intrinsic to collaborative risk suicide risk
An alternative… C Collaborative A Assessment and M Management of S Suicidality (CAMS)
Overview to CAMS Assessment and Care 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
Collaborative Assessment and Management of Suicidality Creating Collaboration
Attitudes and Approach: Creating Collaboration Standard clinical interactions, including suicide interventions, are clinician-as-expert interviewing the client. ?? ?? ?? DEPRESSION LACK OF SLEEP POOR APPETITE ANHEDONIA ... ? SUICIDALITY ? THERAPIST CLIENT Suicide is a symptom Traditional treatment = inpatient hospitalization, treating the psychiatric disorder, and using no suicide contracts…
Attitudes and Approach: Creating Collaboration Clinician-as-expert does not create collaboration Shame Interrogation Checklist Fear of Client Therapist hospitalization
COLLABORATIVELY ASSESSING RISK: Targeting suicide as the focus of treatment Mood SUICIDALITY PAIN STRESS AGITATION HOPELESSNESS SELF-HATE REASONS FOR LIVING VS. REASONS FOR DYING THERAPIST & CLIENT 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.
Attitudes and Approach: Creating Collaboration SSF Separate the Conceptualize Join with client from suicidality the client suicide together 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…
Attitudes and Approach: Creating Collaboration Commitment strategies Maybe time to break up? Just for a few months? Ambivalence I know it’s hard. You can We’ve been always get back together. together so long… Therapist Suicide Client
CAMS SSF: Section A Would you mind if I sat next to you? SSF Suicide. SSF Here’s a pen. I’m going to ask you to do some ratings about how you feel right now. SSF
CAMS SSF Section A Psychological Pain Stress First understand Agitation the experience of Hopelessness suicidality. Self-hate Overall Risk of Suicide This measure is only used during Yourself vs. Others the index session. Reasons for Living and Dying Wish to Live vs. Wish to Die One Thing
CAMS SSF: Review important suicide risk factors Epidemiological Section B Assessment Suicide Plan After understanding the Suicide Preparation experience of suicidality in History of Suicidality Section A, ask for the SSF Current Intent and complete Section B. Impulsivity Can I take this back for us to Substance Abuse go through the other side? Significant Loss Interpersonal Isolation Section C SSF
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