reducing short term suicide risk after hospitalization...
TRANSCRIPT
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
CAMS 6/5/18
Kate Comtois, U of WA. [email protected] 2
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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Kate Comtois, U of WA. [email protected] 6
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
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…
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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 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 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 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.”
CAMS Crisis Response Planning:An Orientation and Philosophy of Care
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…
CAMS Crisis Response Planning:An Orientation and Philosophy of Care
CAMS 6/5/18
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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 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
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