Overview of CAMS Treatment Manual

Reading Managing Suicidal Risk: A Collaborative Approach will provide you with the broad theoretical foundation necessary to facilitate treatment using the CAMS clinical framework. Key concepts covered include: identification of suicide risk, collaboration, and the importance of focusing on factors related to the suicidal wish. In CAMS, suicidal thoughts and behaviors are is defined as thoughts about death without intent to engage in suicidal behavior, active thoughts about suicide, active planning for suicide, active preparatory behavior for a suicidal act, and active attempts to die by suicide.

It is important to understand that CAMS is not a new psychotherapy per se, like cognitive-behavioral or interpersonal psychotherapy which specifies what the therapist should do throughout the treatment. Rather, CAMS is more properly understood as an outpatient suicide-specific therapeutic framework intended for patients who are drawn to suicide as a way of coping. The term “therapeutic framework” reflects the non-prescriptive nature of CAMS, in that the therapist is given much flexibility in case conceptualization and specific treatment approaches to address factors related to suicide. In other words, you are free to use all of your professional experience and range of interventions in your clinical toolkit when working within the CAMS framework. However, two of the key requirements in CAMS are the expectation that your clinical work must focus on addressing the factors which lead to your patient wanting to die by suicide and that this work must be conducted in a fully collaborative manner with both patient and therapist guiding and engaging in the process.

While Managing Suicidal Risk provides the broad foundation for doing CAMS, it is not a highly structured treatment manual. It describes why your work should focus directly on suicide and the benefits of such a focus. In contrast, the goal of this manual is to provide you with specific and concrete suggestions regarding how you can use the CAMS framework to help an individual patient address their suicidal thoughts and behaviors with the ultimate goal of choosing to live. This manual is thus intended to provide the therapist with an overview of the different aspects of CAMS in order to increase the ease with which adherent CAMS-oriented care is delivered. While primarily flexible, there are certain aspects of adherent CAMS care that are essential and should be addressed collaboratively during each individual session. To help facilitate therapists do this, the manual is divided into four major sections: 1) Therapeutic Philosophy; 2) Suicide Risk Assessment; 3) Stabilization Planning; and 4) Clinical Session/Framework. The Therapeutic Philosophy section focuses on the ways in which the therapist interacts with the patient during the session and can be thought of as the essence of CAMS. The Therapeutic Philosophy guides how the therapist conducts the session. The second through fourth sections guide what the therapist does during the session. Sections two and three focus on suicide risk assessment and managing acute suicide risk (i.e., stabilization planning). The fourth section, Clinical Session/Framework, focuses on creating and implementing the treatment plan to assist the patient to replace suicidal coping by developing more effective coping strategies to manage current stressors.

It is believed that therapists from diverse theoretical orientations with a wide range of experiences treating suicidal patients can successfully use the book and this manual to help suicidal patients. You do not have to be an expert suicidologist in order to organize your clinical work within the CAMS framework. However, you do need to be a clinician who is open and willing to think differently about how to approach clinical work with suicidal patients to potentially help save a life.

Key documents that you will use to facilitate treatment are located at the back of this manual and are referred to throughout the manual.


Therapeutic Philosophy

Inherent within all CAMS assessment and treatment strategies is an emphasis on

1)  Collaboration

2)  Focusing on factors related to suicidal thoughts and behaviors

1) What Does Collaboration Look Like in CAMS?

We define collaboration as the therapist and patient working together towards a common goal. While most therapists would agree that a one-sided approach is unlikely to lead to meaningful changes in patient behavior, this is readily apparent in regard to suicidal risk. Consider common reactions that therapists may experience upon learning that their patient is considering suicide:

·  Fear

·  Anger

·  Avoidance

·  Denial

Now consider what behaviors may be associated with these emotions:

·  Unnecessary hospitalizations and referral to emergency departments

·  Implicit and explicit messages to the patient that the therapist wants out of the therapeutic relationship

·  Shaming the patient for having suicidal urges

·  Communicating that something is “wrong” with the patient for experiencing death-related thoughts or a desire to be dead

·  Minimizing risk because they “know” their patient well enough to predict whether a suicide attempt would ever occur

·  Conveying a preference that the patient deny or minimize suicidality

Thus, the impact of therapist behavior on a patient’s willingness to engage in honest and open dialogue about suicidality cannot be understated. For example, let’s revisit an image from the CAMS book (Jobes, 2006), in which a clinician is engaging a patient in a discussion regarding suicidality.

As you can see, the clinician is speaking down to and “at” the patient about suicide with lots of impersonal questions rather than working to understand what is actually happening from the patient’s perspective. Such a position may be more about controlling the patient rather than understanding them. Also, the clinician is conceptualizing suicidal ideation as indicative of a major depressive episode, because that is one place where it appears in the Diagnostic and Statistical Manual of Mental Disorders. Do you think this is how a person actually experiences being suicidal – as a symptom of a psychiatric disorder?

Now let’s view an image that represents a collaborative relationship in regards to the patient’s experienced suicidal thinking.

Here, the clinician has aligned with the patient around the factors that underlie their suicidal ideation. In order to foster a collaborative relationship, the clinician has actually moved next to the patient to complete an assessment of suicidal thoughts and behaviors called the Suicide Status Form (SSF), which will be covered in more detail later in the manual. What’s important to note is the way in which the clinician is trying to gain an understanding of what it means to the patient that they are experiencing suicidal thoughts. This is related to one of the keys to building collaboration in CAMS: expressing empathy for the suicidal wish.

Expressing Empathy for the Suicidal Wish to Facilitate Collaboration

Expressing empathy for the suicidal wish requires the therapist to comprehend how the patient’s thoughts, emotions, and behaviors have led to current suicidal thoughts and/or behaviors. This could also include certain themes regarding life and death that apply to the patient experiencing suicide as a possible solution for current life circumstances. Inherent to this process is the understanding the unique suicidal drivers for each patient. This is a concept we will refer to frequently throughout the manual. Essentially these drivers are the unique factors which lead to this patient desiring death which must be targeted and effectively treated for him or her to choose life over suicidal coping. The distinction between so called “direct” and “indirect” drivers is explained in a later section of the manual.

Important*

Empathy for the suicidal wish is not the same as agreeing to or endorsing suicide as a coping option, but rather, reflects the extent to which the therapist communicates an accurate emotional understanding and acceptance of the patient’s experience of their suicidal thoughts and/or behaviors. Empathy indicates that it is understandable that the patient is currently experiencing suicidal ideation or had engaged in past suicidal behavior given the patient’s suicidal drivers.

What Does Expressing Empathy for the Suicidal Wish Convey to the Patient?

Expressing empathy for the suicidal wish helps the therapist avoid an unhelpful power struggle with the patient around the subject of suicide. The bottom line is that the patient is the only one who can determine the extent to which suicide remains an option over time. So, it is best to acknowledge that suicidal coping may be perceived as an effective means for dealing with profound suffering. Although it may seem counter intuitive, empathizing with your patient’s wish to die (i.e., acknowledging you understand why they settled on suicidal thoughts and/or behaviors as a way of coping with their direct and indirect suicide drivers) paradoxically goes a long way toward helping them to ultimately renounce suicidal coping. This approach allows you to acknowledge that thinking about suicide or engaging in suicidal behaviors are ways of coping, while also highlighting the extreme, irreversible, and interpersonally destructive nature of this strategy. You can always forthrightly share your own suicide prevention bias but still be empathic of your suicidal patient. In other words, we say to the patient “I hear where you’re coming from, this doesn’t scare me, and I believe I can help you find alternatives to getting your legitimate needs met.”

A few clarifying examples of empathy for the suicidal wish:

  1. “A real Soldier wouldn’t consider suicidal thoughts. Stop being weak and selfish.”

·  A therapist who shames or belittles the patient for experiencing suicidal thoughts and/or feelings is not consistent with CAMS philosophy.

  1. “You shouldn’t be considering suicide – look how many people care about you!”

·  Here the therapist is trying to help the patient see what “should” seem worth living for, but it reflects the therapist’s own perspective rather than the patient’s. Again, this is not representative of CAMS philosophy.

  1. “You have more suicidal thoughts when you get upset.”

·  This is a reflection of what the patient experiences, but it could be more detailed in order to convey a true understanding of the suicidal wish back to the patient and could also involve more overt collaborative language.

  1. “So based on our conversation, fantasizing about suicide has been the most effective way for you to take your mind off of really painful memories about Iraq. I can see how that would be a hard thing to give up without a good replacement. I also hear you saying that suicide seems like a good option because you think that it would provide a real solution to so many of the problems you face.”

·  A therapist who conveys an appreciation of how suicide functions for the patient does an excellent job reflecting CAMS philosophy.

Typically, the therapist’s level of comfort and openness about discussing suicidal thoughts and behaviors is ultimately mirrored by the patient’s, although this kind of comfort may take some time given the patient’s history with the mental health system around issues related to suicide (e.g., if disclosing suicidal ideation has previously led to loss of status with the unit, a Soldier would not be expected to be comfortable discussing it openly early in CAMS).

A unique aspect of CAMS is that the therapist/patient relationship, referred to as the “dyad” from here on out, is essentially built around a shared focus on suicidal thoughts and behaviors. In so doing, the dyad develops a shared appreciation for various factors underlying the patient’s suicidality, which ultimately leads to enhanced rapport, risk assessment, and treatment planning of meaningful alternatives (without endorsing suicide as an effective coping option).

Do I Need to Talk a Lot in Order to be Collaborative?

No! While a wallflower therapist certainly would not be considered collaborative, CAMS does not prescribe a ratio of talking and active listening during session. The most essential element of collaboration is that the therapist remains actively engaged throughout the session in seeking to learn and summarize the factors related to suicidal ideation and behaviors, and suggest and discuss (but not prescribe) matching intervention strategies.

As shown in the figure above, the assessment of factors related to suicidal thoughts and behaviors is overtly collaborative. Therefore, although the therapist may have his/her own beliefs regarding the underlying factors leading the patient to experience suicidal thoughts, it is important to incorporate the patient’s own hypotheses regarding suicide into all assessments and reflect them back to the patient.

Remember: One of the hallmarks of CAMS as a therapeutic framework and not a specific psychotherapy is that the case formulation need not be based on any one specific underlying theory. While the case formulation must be seen as valid from both the patient’s and therapist’s perspective, it can reflect clinical factors from a range of backgrounds, including but not limited to interpersonal, cognitive-behavioral, and humanistic theories related to suicide.

A few clarifying examples of collaboration when assessing a patient’s suicidal thoughts and/or behaviors:

  1. “I know why you are experiencing suicidal thoughts. It’s common for Soldiers to feel survivor guilt and I see it all the time in Soldiers struggling with how to make sense of their experiences in combat. I’m sure that’s what’s happening with you."

·  A therapist who informs the patient why they are suicidal without investigating the patient’s perspective does not reflect CAMS philosophy.

  1. “I can see why feeling like a burden is related to your suicidal thoughts, but I think that hopelessness is really a bigger factor for you at the end of the day."

·  Here the therapist accurately reflects the patient’s beliefs, but more could be done to collaboratively determine factors underlying the patient’s suicidality.

  1. “I see that you ranked “Self-Hate” as the most pressing concern on the SSF. That’s something I think we could target in our work together. Could you tell me more about that? While I have known some Soldiers who experience similar thoughts and feelings, I would like to know how hating yourself is specifically linked to suicidal thinking for you.”

·  This interaction represents CAMS philosophy regarding assessment, as the clinician accurately reflects and validates that self-hate has been experienced by others in similar situations, while also acknowledging that the patient is always the expert on their own experience.