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E. Galavan handout


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Collaborative Assessment and Management of Suicidality

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E. Galavan handout

  1. 1. Collaborative Assessment and Management of Suicidality Lithuania Conference October 2016 Dr Eoin Galavan
  2. 2.  The prevailing model/culture of addressing suicide in mental health care  What can be done differently  Collaborative Assessment and Management of Suicidality (CAMS) • Model and evidence for effectiveness  The story of establishing a suicide specific service  Using CAMS in Community Mental Health Teams (CMHTs)  CAMS case examples  Declaration of interest: CAMS-care consultant
  3. 3. ?? ?? ?? THERAPIST PATIENT Critique of Current Approach to Suicide Risk: THE REDUCTIONISTIC MODEL (Suicide = Symptom of Psychopathology) DEPRESSION LACK OF SLEEP POOR APPETITE ANHEDONIA ... ? SUICIDALITY ? Traditional treatment = inpatient hospitalization, treating the psychiatric disorder, and using no suicide contracts…
  4. 4. The Collaborative Assessment and Management of Suicidality (CAMS) identifies and targets Suicide as the primary focus of assessment and intervention… THERAPIST & PATIENT PAIN STRESS AGITATION HOPELESSNESS SELF-HATE REASONS FOR LIVING VS. REASONS FOR DYING Mood CAMS assessment uses the Suicide Status Form (SSF) as a means of deconstructing the “functional” utility of suicidality; CAMS as an intervention emphasizes a problem-focused intensive outpatient approach that is suicide-specific and “co-authored” with the patient… Suicidality
  5. 5. 5 Psychotherapeutic Philosophy Negligence/Obligati ons to client Risk Management and Treatment Planning Strategies Statics Risk Factor Research CAMS
  6. 6. “CAMS is an overall process of clinical assessment, treatment planning, and management of suicidal risk with suicidal outpatients”
  7. 7.  With 50-80 RCTS with suicidality as an outcome variable  There is mixed support for medication-only approach  RCT’s and replications support: • Dialectical Behavior Therapy (DBT) • Cognitive Therapy for Suicide Prevention (CBT-SP) • Collaborative Assessment and Management of Suicidality (CAMS) • Non-demand follow-up contact (caring contacts)
  8. 8. Authors Sample/Setting n = Significant Results____ Jobes et al., 1997 College Students 106 Pre/Post Distress Univ. Counseling Ctr. Pre/Post Core SSF Jobes et al., 2005 Air Force Personnel 56 Between Group Suicide Outpatient Clinic Ideation, ED/PC Appts. Arkov et al., 2008 Danish Outpatients 27 Pre/Post Core SSF CMH Clinic Qualitative findings Jobes et al., 2009 College Students 55 Linear reductions Univ. Counseling Ctr. Distress/Ideation Nielsen et al., 2011 Danish Outpatients 42 Pre/Post Core SSF CMH Clinic Ellis et al., 2012 Psychiatric Inpatients 20 Pre/Post Core SSF Suicidal Ideation, depression, hopelessness Ellis et al., 2015 Psychiatric Inpatients 52 Suicide ideation/cognitions
  9. 9. _______________________________________________________________ Principal Setting & Design & Sample Status & Investigator Population Method Size Update_____ Comtois Harborview/Seattle CAMS vs. TAU 32 2011 published (Jobes) CMH patients “Next-day” appts. article Nordentoft Danish Center DBT vs. CAMS 108 2016 published (Aamund) CMH patients superiority trial article Jobes Ft. Stewart, GA CAMS vs. E-CAU 148 Final 12 mo. (Comtois) US Army Soldiers data collection Fosse Norwegian Centers CAMS vs. TAU 100 ITT underway CMH patients on-going Pistorello Univ. Nevada—Reno SMART Design 60 ITT recruited; (Jobes) CC Students TAU/CAMS/DBT post-assess Comtois Harborview/Seattle CAMS vs. TAU 200 IRB approved (Jobes) CMH patient Post-Inpatient D/C Training prep
  10. 10.  From two diverse samples there were 636 written responses to SSF prompts (n = 152).  Collapsing data across constructs, 22% of responses pertain to Relational issues.  20% of written responses pertained to issues of Role Responsibility.  15% of responses related to issues of Self.  10% of responses related to Unpleasant Internal States.  Collapsing across constructs, 67% of responses were related to relational issues, vocational challenges, self-related concerns, and internal emotional distress.
  11. 11. Suicide Assessment and Treatment Service, 2013 No suicidal people currently on clinical psychology wait lists Referrals made at weekly MDT, or via email Training, consultation and supervisory role for other CMHT staff 2 hours/week allocated to the SATS service 10-14 Clinical Psychologists (5 trainees) covering 7 CMHTS, mental health for older persons, mental health for intellectual disability, acute inpatient care
  12. 12. Management “by in” as a policy decision Used by the team as the means by which the service addresses suicidality within the service user population Systematic use: a coherent plan about how to utilise the resource within those people who are using the CAMS Several users, with some arrangements/agreements about how to adapt, often implicit Sole users
  13. 13. Does the CAMS ‘take more time’? More time than what? It takes time to do a thorough thoughtful collaborative risk assessment, treatment plan and stabilisation plan
  14. 14. Whose responsibility is it anyway? Every mental health clinician has a responsibility to be able to meet and manage suicidality Practical reality of leaving it to one discipline is unworkable
  15. 15.  Suicidal people equal threat and trouble  Unconscious effort to push it away or prove the risk is less than it really is “they are not really suicidal” or “they don’t really mean it” or  prove it is more than it really is to justify admission criteria “I’m very worried and it wouldn’t surprise me if they did it so I think we should admit”  Hate in the Countertransference: • they are not really sick, this is just behaviour, they are manipulative, they are just looking for attention  I don’t want to work with them when they are suicidal, I want them in hospital until they are not suicidal, then I will work with them
  16. 16.  Large, M. & Ryan, C. J. (2014). Disturbing findings about the risk of suicide and psychiatric hospitals (Editorial)  Hjorthoj, C.R., et al (2014). Risk of Suicide according to level of psychiatric treatment—a nationwide nested case control study. Found a strong dose effect relationship e.g. admitted patients had a 44.3 times the risk of suicide  Fear often drives admission  Admission may in the short term reduce risk for some, or at least it is perceived to do so (reduced access to lethal means, increased social contact inherent in an inpatient stay)  No admission is without risk (10-20% of deaths by suicide in UK adult mental health patient population occur in acute care)  However it may also be true that admissions increase risk and even cause suicide (shame, stigma, disappointment, mismatch of intervention/environment and problem type, reinforcing suicide as a means to solving problems)  “We believe it is likely that a proportion of people who suicide during or after an admission to hospital do so because of factors inherent in that hospitalisation” (Large & Ryan, 2014)
  17. 17. 1. Issues of sufficient informed consent. 2. Issues of competent assessment of risk. 3. Need for empirically-oriented treatments. 4. Appropriate risk management (liability issues).
  18. 18.  What works wins!  Don’t negotiate to start doing something, there are a million creative reasons to tell you to stop  Do something, and allow people the option of telling you to stop… Please stop delivering this thoughtful, comprehensive, evidenced based, collaborative, ethically minded, problem focused, well documented, risk assessment, risk management and suicide specific intervention
  19. 19. Heard about CAMS? Id like to start a project …what do you think? Never heard of it No time Not possible
  20. 20. We’ve been using a model called CAMS. Look it works. Here’s the audit of recent cases You’ve been seeing suicidal people? What does CAMS mean? Here’s another referral
  21. 21.  Recommended model of training includes • 3 hour online training program, plus • 1-1.5 days live role play training, plus • Participation in approx 8 case consultation calls • Full adherence/mastery usually takes 2-4 completed cases • Decreases in anxiety about working with suicidal patients pre-post training, increases in confidence in assessing and treating suicidal behaviour. No differences across staff groups (Jobes, 2016) • Rates of clinician behaviour change vary, approx 40% in our local audit, with a large study underway to explore this further (Jobes 2015) • Post training consultation a major contributing factor to whether the model is used or not post training
  22. 22. Nscience 1 day training, London 22nd October, Ambassadors Bloomsbury Hotel, CAMS training Queries re CAMS training see or contact me on