The CAMS/SSF Blog by G. Collerone all rights reserved, copyright 2015
Despite the increase in awareness of suicide as a major psychological health problem, gaps remain in training programs for mental health professional, or even health care professionals who often come into contact with suicidal patients in need of these specialized assessment techniques and treatment approaches.
CAMS (Collaborating, Assessment, and Managing of Suicidality) was developed to modify clinician behaviors in how they initially identify, engage, assess, conceptualize, treatment plan, and manage suicidal outpatients. At the heart of the CAMS approach is an emphasis on a strong therapeutic alliance where counselor and client work closely together to develop a shared understanding of a client’s suicidal phenomenology.
CAMS is designed to specifically target suicidal ideation and behavior as the central clinical problem, independent of diagnosis. Within CAMS, there is a basic belief that suicidal thoughts and behavior represent a fundamental effort to cope or problem solve, in pursuit of meeting legitimate needs (e.g., needs for control, communication of pain, or an end to suffering).
Ironically, the counselor’s capacity to understand and appreciate the viability and attraction of suicide as a means of coping provides the essential ingredient for forming a strong therapeutic alliance where more adaptive methods of coping can be evaluated, explored, and tested.
Philosophically speaking, CAMS emphasizes an intentional move away from the directive “counselor as expert” approach that can lead to adversarial power struggles about hospitalization and the routine and unfortunate use of coercive “safety contracts” (Jobes 2000, 2006)
Suicide Status Form, the CAMS assessment tool, uses Likert and qualitative open ended items related to the client’s psychological pain, stress, agitation, hopelessness, self-hate, and overall suicide risk. Throughout the assessment process, the client’s perspective is treated as the assessment gold standard. We suggest the regular use of brief symptom assessments collected at every clinical contact is analogous to medical personal routinely taking a patient’s vital signs to monitor overall physiological functioning and health.
This blog will discuss in detail the underpinnings of the CAMS model as well as its assessment tool, the Suicide Status Form (SSF). This blog uses multiple references that will be posted at the end of the post.
The reason I am writing this Blog is not only to disseminate the information of David Jobes’s work, but also to bring something that is easy to administer in a timely fashion, provided the client is English speaking, literate, and cooperative. The beauty of this assessment tool is that it can be used as part of the client’s medical record. There doesn’t have to be additional paperwork with the SSF as it already has the documentation required. Granted, I am not a clinician, so guidelines may be different but I think most places and practices has to have the axis’s and GAF score. I could be wrong about this but do what is best for your practice and clinic.
Another reason I am writing about this important work is that it saved my life and countless others. I believe in this so much that it is all I talk about when someone mentions suicide prevention. That is how strongly I believe in this brilliant seminal work. I think that if every clinician had this at their disposal, less suicides would happen. And isn’t that the goal that should be achieved?
CAMS, the Collaborating, Assessment, and Managing of Suicidality, came about from the need of one clinician-researcher to keep track of suicidal patients, to monitor their progress, to assess, manage, and collaborate with suicidal clients. The framework and research was done over a period of twenty-five years. The need to have something better than “no suicide contracts” and long assessment forms had to happen. There had to be an evidence based treatment and assessment tool out there as the days of long hospitalizations for depression were over. Many clients who were deeply suicidal were only kept for one to three days, tops. Soon as they were admitted, talk of discharge were discussed, much to the chagrin of the outpatient clinician. What was going to help the clients see another way out of their pain and misery?
In his book, Managing Suicidal Risk, Jobes realized four assumptions of why clinicians were reluctant to use suicide assessment instruments:
• Over reliance on clinical interviewing
• Wide spread perceptions that suicide risk assessments are clinically intrusive or simply too long
• Most existing instruments are atheoretical. Clinicians do not know the meaning of an obtained risk score
• Common perception that these instruments fail to fundamentally capture essential but elusive aspects of suicidality.
The end result was coming up with a framework and assessment tool that was evidence based, easy to administer and code, assess overall suicide risk, and have a treatment plan in place that both clinician and client agreed on. Behind the name of “managing suicide risk”, there is a double meaning of clinical work with suicidal clients is best performed by collaborating, managing the issue with the client, and in turn such an approach makes the whole challenge of working with suicidal risk much more manageable for the clinician. CAMS can be quickly learned and readily used with new cases, or with ongoing cases, wherever suicide risk is present. It is not meant to be a stand alone treatment but rather serves as a practical method that can be added to a standard treatment approach, a tool already existing in any mental health professional’s toolbelt.
The SSF (Suicide Status Form) is the tool that is used with CAMS and is made up of seven different pages that are divided into three phases of clinical care
• Index Assessment/treatment planning (pg 1-3)
• Clinical tracking (pg 4-5)
• Clinical outcome (Pg 6-7)
Thus, there are three distinct phases of the SSF that I will attempt to discuss in detail that are used within the process of using CAMS with any suicidal client. (I.e., there are distinct phases that include a beginning, a middle and an end.)
The first phase of CAMS require the first three pages that assess the suicide client. It uses four distinct sections. The first section (A) are Likert ratings. The first three Likert assessment construct (pain, perturbation, press) are based on the work of Edwin Shneidman (1988) and these make up the “cubic model of suicide”. The 4th item is hopefulness bases on Beck’s work. The 5th item, self hate, is based on Baumeister work of escape theory of suicide. He links intolerable perceptions of self to a need for suicide escape (see this blog post for more information on his work).
Psychological pain or as Shneidman has named it, psychache, is a profound and seemingly unbearable suffering that exists in the mind’s eye of the suicidal person. The psychological threshold has been exceeded and suicide occurs. Not everyone’s tolerance of psychache is the same. It is unique to each suicidal client.
Press (stress) is what Shneidman borrows from Murray (1938). For our purposes, the term refers to largely external (sometimes internal) pressures, stressors, or demands that impinge upon, touch, or psychologically affect an individual. External things such as relational conflicts, job loss, or events that occur in life that create significant distress. Alternatively, however, internal stressors such as command hallucinations can be similarly distressful. Presses are intimately linked to overwhelming feelings: the perception that I am overpowered by psychological demands. For the sake of clarity, further descriptions of press will be referred to as stress.
Perturbation, the second ‘P’, is a unique and crucial construct that is distinct and different from psychological pain. Shneidman defines perturbation as the state of being emotionally upset, disturbed, and disquieted. In his thinking, perturbation includes both cognitive constriction (narrow-minded or one way thinking) and need for self-harm or ill-advised action. It can be described as the “need to do something” to change the unbearable situation.
The “cubic model of suicide” conceptualizes suicidal behaviors that occurs from the synergy of these three constructs (psychache, perturbation, and press (stress); also known as the three P’s) They are rated on a Likert scale of 1-5. It is believed that should a score of 5-5-5 occurs, suicide is imminent and is therefore lethal.
This Cubic Model of Suicide is the hub of the SSF. It provides a three dimensional window into the client’s suicidal mind that meaningfully eclipses any one dimensional linear way of thinking about suicide risk assessment.
The next item on the SSF in Section A is hopelessness. No single construct has been more highly correlated with completed suicide than hopelessness. Jobes felt it imperative to include hopelessness as a key SSF construct. It provides an organizing focus for treatment. The therapist must be “hope vendors”. This notion strikes him as being uniformly true and central to successful treatment in general and particularly when working with suicidal people.
The next item in Section A is self-regard (self-hate). Baumeister conceptualized suicide as an escape from self. In his view, suicidal people are fundamentally driven to psychologically escape as a way to get rid of themselves. According to Baumeister’s theory, one’s negative view of self can become so unbearable (i.e., one’s self-loathing and self-hate is so extreme) that suicide becomes a compelling means to escape intolerable perception of self. Simply put, there is an intense psychological need for escape. It is perhaps self-evident that people who love themselves are fundamentally comfortable with who they are and most likely are not inclined to take their lives. Thus the beauty of Baumeister’s conceptual approach is that it captures two essential components of suicide struggle, the need for escape and the core importance of the self.
The behavioral assessment of suicide risk is the final component of the SSF. This construct, the Likert question of overall risk of suicide, does not cite any theorist. In this regard, the 6th item simply asks the client if they will or will not kill him or herself. The question is asked to the obvious implications for life and death and determines the medicolegal challenge to whether there is “clear and imminent” risk for suicide behavior. Suicidal states are much more shades of gray rather than crystal clear. They are hardly ever “clear”. And imminent is further convoluted as it could mean this second, later today, or sometime next week. While these definitions are elusive, these terms are important for the safety of the client and have significant implications for the potential liability of the clinician should a complete suicide occurs. Therefore, it made sense to include this risk as a final Likert construct on the SSF.
Next section: Qualitative SSF Assessments
This is a novel idea because most psychological assessment tools are either qualitative or quantitative. The SSF includes both to provide a much fuller picture of virtually any suicidal state. The three different qualitative assessments are 1) the Likert prompts, 2) Reasons For Living vs. Reasons For Dying (RFL/RFD), and 3) the one thing response.
The Likert prompts provides the clinician information about the client’s suicidal mind in his/her own words. For more information about the coding of these responses, see pages 18-19 of the book. But for the most part, in my opinion, these responses are straight forward to what the client is dealing with in this crisis and what is driving them to think suicide is the answer.
The SSF RSF/RFD was built upon the important work of Marsha Linehan (1983). She developed the reasons for living inventory. Linehan had the novel idea of studying suicide risk assessment in an entirely different way. With dozens of studies dedicated to risks factors and why people might want to die, Linehan argued that an equally compelling assessment notion was the value of examining why any person might want to live. The absence of RFL could be inversely correlated to increased suicide risk. In an opposite fashion, Jobes built the reasons for dying inventory in the same assessment (Jobes and Mann, 2000). These assessments provide a tool that parallels no other risk assessment in the literature that tells a picture of the client’s suicidal mind, in my opinion.
The one thing response gathers information directly from clients about the one thing that would make them no longer suicidal. This provides the clinician with potentially more clinical information that leads directly to a treatment intervention. For example, if the client state that being in less pain would make them no longer suicidal, the clinician can work with the client to decrease that pain.
Section B has the SSF empirically-based risk variables on the second page of the initial form. These risk factors have been well researched risked factors that are the best variables for suicide risk.
Section C is the wonderful piece of the SSF. It is the section where both the client and clinician come up with a treatment plan, together! In this section, treatment goals, length of treatment, crisis response plans, and specific interventions are discussed. For the Crisis response plan example, please check out this blog post. It emphasizes what the client will do should he/she become intensely distressed, impulsive, and suicidal. These measures are clearly planned in anticipation of potential crises. This becomes a contract where the client then signs in agreement.
The tracking form (pg 4-5) omits sections b and c. It assesses similar to the initial form. It was created so that the suicidal feelings are “tracked” and monitored. This is to be used until the suicidal thinking has resolved for three sessions. The outcome form (pg 6-7) describes the overall experience of the crisis and provides feedback to the clinician. It also assesses the Likert ratings to be sure the suicidality has been sufficiently dealt with. If the client should become suicidal at anytime before the outcome is used, then a new initial form should be evaluated again.
All three forms then have sections that provide post session evaluations. There is a space for clinical notes as well as the mental status of the client. It also has information regarding the outcome of the appointment and when the next scheduled appointment is. That is the beauty of this assessment tool. No extra paperwork!
here is the DSM IVR Form
Update 23/November/2016 Dr. Jobes has a 2nd Edition of the Managing Suicide Risk that is available through eBooks. It has the DSM V form of the SSF. I am unable to load it at this time, as I do not have his permission to load it on my blog. If I am able to find an electronic version of it, I will place it here instead of the DSM IV version. Thank you for reading.
Jobes, D. A., Moore, M. M., & O’Connor, S. S. (2007). Working with Suicidal Clients Using the Collaborative Assessment and Management of Suicidality (CAMS). Journal of Mental Health Counseling, 29(4/October), 283-300.
Jobes, D. A. (2006). Managing suicidal risk: A collaborative approach. New York, NY: Guilford Press.
Jobes, D. A. (2012). The Collaborative Assessment and Management of Suicidality (CAMS): An Evolving Evidence-Based Clinical Approach to Suicide Risk. Suicide and Life Threatening Behavior, 42(6), 640-653.
Murray, H. A. (1938). Explorations in Personality. New York: Oxford University Press.
Linehan, M., Goodstein, J., Lars Nielson, S., & Chiles, J. (1983). Reasons for Staying Alive When You Are Thinking of Killing Yourself: The Reasons for Living Inventory. Journal of Consulting and Clinical Psychology, 51(2), 276-286.
Jobes, D. A., & Mann, R. E. (1999). Reasons for Living versus Reasons for Dying: Examining the internal debate of suicide. Suicide and Life-Threatening Behavior, 29(2), 97-104.
Jobes, D. A. (2009). The CAMS Approach to Suicide Risk: Philosophy and Clinical Procedures. Suicidologi, 14(1).
Baumeister, R. (1990). Suicide as Escape From Self. Psychological Review, 97(1), 90-113.
Shneidman, E. S. (1993). Suicide as psychache: A clinical approach to self-destructive behavior. Lanham, MD: Jason Aronson.
Shneidman, E. S. (1996). Suicide as psychache. In J. T. Maltsberger & M. J. Goldblatt (Eds.), Essential papers on suicide (pp. 633-638). New York, NY: New York University Press.
Oordt, M. S., Jobes, D. A., Fonseca, V. P., & Schmidt, S. M. (2009). Training Mental Health Professionals to Assess and Manage Suicidal Behavior: Can Provider Condience and Practice Behaviors be Altered? Suicide and Life-Threatening Behavior, 39(1), 21-32.
copyright 2015, Collerone, G