CAMS, COVID-19, and Overcoming Challenges

With plans to start a large National Institute of Mental Health (NIMH) funded multi-site Comprehensive Adaptive Multisite Prevention of University Student Suicide (CAMPUS)feasibility trial in the Fall of 2020, our massive study, like so much else in the world, was turned upside down by the COVID-19 pandemic. NIMH agreed to our proposal to hold off the start of our investigation of CAMS vs. Treatment as Usual vs. Dialectical Behavior Therapy, involving 700 college students who are suicidal. They also agreed to support an initial feasibility trial investigating the use of online training and delivery of study treatments via telehealth.

To this end, we have learned much about training and delivering care online, as well the use of Zoom and a form-fillable PDF version of the Suicide Status Form. We worked out the challenges of doing a large and complex multi-site trial. If all goes well, the main trial will begin this coming academic year, and will offer treatments online, face to face, or as a hybrid. This depends on how the pandemic plays out and emerging university policies.

Reflections on “Raising CAMS”

It was Sunday morning and I had just watched a handful of CAMS sessions for adherence and fidelity purposes. You might think that I, as the developer of CAMS, would always relish training, supervising, consulting, and empirically studying the intervention that has been my life’s work. In truth, as much as I enjoy working with my clinical “baby,” I sometimes get too much of CAMS! I talk about CAMS every day during professional webinars, presentations, in my classes, and my writing. Plus, I am immersed in a number of on-going clinical trials investigating how it works and for whom it works best. It is a little odd to admit that sometimes I am inundated by something so near and dear to me. It is, after all, my life’s work and I am immensely proud of it.

I do not wish to complain about the accomplishments related to the development, study, and use of CAMS. I feel blessed by my amazing colleagues, our empirical clinical research, and the success of training thousands of clinicians around the world! But as I have blogged about before, there have been setbacks and disappointments. It can be exhausting to argue with those who do not believe credible research or fight against the use of CAMS for unclear reasons. It wears me down and contributes to my occasional bouts of CAMS fatigue. But,watching sessions of therapists beginning CAMS has renewed my excitement in the intervention anew!

A Perspective on CAMS

Let me share a case with aspects disguised to ensure the confidentiality of the clinician and the client. “Kerry” is a clinical psychologist at one of the CAMPUS university counseling centers. She is seeing “Denise,” a Ph.D. graduate student who studies biology. Denise has struggled with depression as well as intermittent suicidal and self-harm impulses for years, but her suicidal thoughts increased during the pandemic as she has felt isolated and culturally lost. She moved from the deep south to a different part of the United States to attend graduate school, and she feels overwhelmed by research work. Denise also recently broke up with a serious boyfriend.

The session was Kerry’s first CAMS case; she trained with my team in early January . Kerry used the new fillable PDF of the Suicide Status Form (SSF) and spoke with Denise on a secure Zoom platform. I watched the session remotely and securely on my laptop using a method that has been reviewed and approved by multiple Institutional Review Boards. Like the rest of my team doing fidelity work, I completed a CAMS Rating Scale to evaluate Kerry’s adherence to the CAMS framework.

I found myself mesmerized by Kerry’s inaugural sessions using CAMS. Denise was bright, but also lost psychologically. She was very open to Kerry’s efforts to initiate CAMS and the dyad dove into the first session SSF assessment as Kerry worked as Denise’s scribe. Denise approached each SSF assessment question thoughtfully before responding, while Kerry respectfully waited to record her responses. They worked their way through the first page and uncovered clear long-standing and short-term issues that seemed to be part of Denise’s current struggles. They moved on to review her risk and warning signs: thoughts of jumping into traffic and cutting herself intrusively interrupted her daily life. As they delved into the CAMS Treatment Plan phase of their session, they crafted a strong and sensible CAMS Stabilization Plan that emphasized reducing access to sharp instruments in her apartment and avoiding certain intersections. It also included different coping strategies (e.g., playing video games, yoga, and knitting). At the end of the session, it was clear that Denise’s two problem-drivers were “loneliness” and “self-hate.” At that point, Kerry had many ideas about how to attack these drivers with behavioral activation, CBT techniques, Mental Time Travel for Suicidal Self-Hate, and other insight-oriented work.

Kerry’s excitement was palpable as she observed Denise’s wonder, curiosity, and surprise at what they uncovered in a full 50-minutes. This blossoming therapeutic relationship and the hope that Kerry installed in Denise was CAMS magic right before my eyes! As the client, Denise had her experience validated by her thoughtful clinician. And, to her amazement, the many interventions Kerry mentioned are designed to treat the problems that compel her to consider suicide. As the clinician, Kerry bravely dove into using CAMS for the first time, and now she is empowered after seeing what she and Denise accomplished in such a short time!

There’s More of This to Come

For my part, my mind swims with all the possibilities to save Denise’s life: Mental Time Travel for sure, the CAMS Therapeutic Worksheet, maybe a Virtual Hope Kit, my mentalization handout, different books… So many options! But first, I have to write an email to the research team to share my renewed excitement and to thank them for all their hard work. I have to tell Colleen because I always share everything with her — not the particulars of the case, but the validation of why we do what we do in the first place. And I need to write a blog post (because it has been a while) to remind myself and others that while the work we do is often challenging, hard, and fatiguing, there are moments of renewal and excitement right around the corner!

To be fair, it does not always go this way in a first session with a client who struggles with suicidal thoughts and impulses. But when it does, it is something to behold. Thank you, Kerry and Denise, for reminding me what CAMS is about!